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Experiences with mental health (MH) and high-risk developmental conditions (HRDC) are challenging to obtain during pediatric residency. This study describes Brief Focused Interprofessional Encounters (BFIE) during a developmental-behavioral pediatric (DBP) rotation. Postgraduate year 1 (PGY1) pediatric residents recorded diagnoses of children they interacted with at each BFIE site and completed a self-assessment at the start and end of their rotation. Of 48 residents, 67% (32/48) completed daily encounter records and 81% (39/48) completed self-assessment surveys. Residents’ self-reports showed significantly higher levels of confidence in 12 learning areas, with the highest gains in bereavement, autistic spectrum disorders, juvenile justice, and teen pregnancy ( Ps < .001). By establishing BFIE customized to the local community, a DBP curriculum can effectively provide measurable, innovative curriculum content that addresses less commonly accessed areas of MH and HRDC; foster interprofessional relationships; and improve resident confidence.

Background Sacubitril/valsartan has been shown to reduce mortality and morbidity inpatients with heart failure and reduced systolic function. However, the effects of this novel association in patients with congenital heart disease and a systemic right ventricle (sRV) have not been investigated yet. Purpose We aimed to assess tolerability and efficacy of sacubitril/valsartan in patients with a sRV Methods From September 2020 to March 2021, 38 patients with congenitally corrected transposition of the great arteries or transposition of the great arteries after Senning or Mustard repair were prospectively enrolled. Inclusion criteria were: age ≥18 years, optimal medical therapy including ACEi/ARB for at least 6 months and EF of the sRV ≤40%. Patients with univentricular physiology, systolic blood pressure (SBP) 5.5mEq/L were excluded. RV systolic function was assessed on echocardiography using a multiparametric evaluation. The study protocol contemplates serial assessments at 1, 3, 6 and 12 months after treatment initiation. Results Up to March 31th, 23 patients completed 1-month and 15 completed 3-month assessment after treatment initiation. Baseline patients' characteristics are summarized in table 1. The medication dose was up-titrated to the highest tolerated dose during follow-up. During early follow-up, no major adverse events were reported. Treatment did not impact significantly on the values of serum potassium (basal K+ 4.4 [4.2–4.6] mEq/L, K+ at 3 months 4.4 [4.3–4.6] mEq/L, p=0.7) and GFR (basal GFR 113.9±35ml/min, GFR at 3 months 107.8±21 ml/min, p=0.7). Although SBP did not change significantly (114±12 vs 113.9±19 mmHg at 1-month and 117.3±12 mmHg at 3 months; p=0.9 for both), 2 (5%) patients ceased the treatment due to symptomatic hypotension during the first month of treatment. There was no significant change in the NYHA class. However, the 6-minute walking distance increased significantly after 3 months (365±120 vs 498.3±71 min; p=0.01). Furthermore, while traditional echocardiographic parameters of RV systolic function (TAPSE, s wave and FAC) did not change significantly, RV global longitudinal strain (GLS) and RV free wall GLS demonstrated subclinical improvement in right ventricular systolic function (table 2). Conclusions Our short-term results from an ongoing prospective study showed that sacubitril/valsartan is well tolerated in patients with a sRV with early evidence of improvement in exercise tolerance and sRV systolic function. Longer follow-up is warranted to confirm these data. Funding Acknowledgement Type of funding sources: None. Table 1Table 2

Hypertrophic pyloric stenosis (HPS) is the most important cause of non-bilious vomiting during infancy and it is usually idiopathic. It is very rare in older children and adolescents, in which gastric outlet obstruction (GOO) is more typically secondary to other conditions. Gastrointestinal malformation are frequently associated with Down syndrome and some of them (especially duodenal abnormalities) can be detected quite late. In infants the standard treatment of HPS is represented by a Ramstedt pyloromyotomy, while in adults a distal gastric resection is more indicated and it is usually associated to a Billroth I or II reconstruction. Case report We present an unusual case of a 12-year-old girl with Down syndrome, diagnosed with late-onset HPS. She came to our attention with periodic non-bilious vomiting and growth delay. She underwent multiple imaging examinations, which highlighted the presence of an HPS. Based on patient's age and the thickness of the pyloric muscle, we decided to perform a partial gastrectomy with a Roux-en-y reconstruction. Patient was discharged on the X day. She is now on follow up, gains weight and presents good conditions. Discussion HPS is rare but possible during childhood and adolescence. Diagnosis is usually performed through ultrasounds (US) and upper gastrointestinal radiological series (UGI), but sometimes further examinations are required (abdominal MRI, esophagogastroduodenoscopy). In older children since less invasive techniques are not effective, we have to consider partial gastrectomy. Based on our experience, Roux-en-y reconstruction is a valid option, associated with poor complication and good quality of life.

O presente artigo descreve uma oficina de Scratch realizada com o objetivo de diminuir o estranhamento entre os professores e as tecnologias. Tal dificuldade foi constatado pelos autores ao perceber o pouco ou mau uso da informática no ensino. Dialoga-se sobre as possibilidades pedagógicas desta ferramenta e da sala de informática para um ensino mais significativo, além de discutir sobre a atuação do professor na sala de informática.

This essay describes the combination of 3D solutions and software techniques with traditional studies and researches in order to achieve an integrated digital documentation between performed surveys, collected data, and historical research. The approach of this study is based on the comparison of survey data with historical research, and interpretations deduced from a data cross-check between the two mentioned sources. The case study is the Basilica of S. Ambrogio in Milan, one of the greatest monuments in the city, a pillar of the Christianity and of the History of Architecture. It is characterized by a complex stratification of phases of restoration and transformation. Rediscovering the great richness of the traditional architectural notebook, which collected surveys and data, this research aims to realize a virtual notebook, based on a 3D model that supports the dissemination of the collected information. It can potentially be understandable and accessible by anyone through the development of a mobile app. The 3D model was used to explore the different historical phases, starting from the recent layers to the oldest ones, through a virtual subtraction process, following the methods of Archaeology of Architecture. Its components can be imported into parametric software and recognized both in their morphological and typological aspects. It is based on the concept of LoD and ReverseLoD in order to fit the accuracy required by each step of the research.

Branchial abnormalities occur when there is disturbance in the maturation of the branchial apparatus during fetal development. Branchial anomalies are congenital lesions usually present in childhood, even if they can be diagnosed later for enlargement or infection. A correct diagnosis will lead to proper management: complete surgical excision is the treatment of choice. The purpose of this article is to present clinical features, diagnostic methods and surgical treatment of branchial anomalies in childhood, based on a series of 50 patients. We conducted a retrospective analysis of a total of 50 pediatric patients operated from June 2005 to June 2014 for the presence of branchial cleft anomalies. 27 cases (54 %) presented a second branchial cleft fistula and 11 cases (22 %) a second branchial cleft cyst and one case (2 %) presented both cyst and sinus of the second branchial cleft; four cases (8 %) presented first branchial cleft cyst whereas four cases (8 %) a first branchial cleft sinus and two cases (4 %) a first branchial cleft fistula; one case (2 %) presented a piriform sinus fistula (third branchial cleft). None of our patients presented anomalies of the fourth branchial cleft. All patients underwent surgical treatment and lesions have been removed by excision or fistulectomy. No post-surgical complication occurred. The rate of recurrence was 4 %. Pre-operative diagnosis supplies important information to the surgeon for a proper therapy: a complete excision of the lesion without inflammatory signs is essential to avoid re-intervention and to achieve a good outcome.

The extent of surgery for pediatric papillary thyroid carcinoma is debatable. The aim of this study was to evaluate the feasibility of offering pediatric patients a tailored surgical approach based on certain clinical features. A national multicenter retrospective review of 250 pediatric patients treated for papillary thyroid carcinoma in a 14-year period was performed. Outcomes of interest included tumor-related features, type of surgery, surgical morbidity, disease-free and overall survival rates. Recurrence was thoroughly analyzed with particular focus on how it correlated with certain patient- and tumor-related features. The majority of patients (58.8 %) had tumors >2 cm in size. Nodal involvement occurred in 115/250 (46 %) patients and distant metastasis in 4 % (10/250). Total thyroidectomy and lobectomy were performed in 90.4 % (226/250) and 9.6 % (24/250) of patients, respectively. The overall rate of surgical complications was 20.8 % (52/250). These included transient and permanent hypoparathyroidism (13.6 and 4.4 %, respectively), and vocal fold palsy (2.8 %). All surgical complications occurred exclusively in the total thyroidectomy group. The rate of recurrent disease was 12 % (30/250) with the vast majority of recurrences (96.6 %) occurring in the total thyroidectomy group. The risk of recurrence correlated significantly with certain tumor-related features (size > 2 cm, multifocality, extrathyroidal invasion, nodal positivity, and distant metastasis). However, it did not correlate with the patient’s age or sex. Overall survival was 100 %. Pediatric patients are likely to benefit from a tailored surgical strategy. Uniformly offering patients total thyroidectomy seems to be an overly radical approach.

Background: Studies of related individuals have consistently demonstrated notable familial aggregation of cancer. We aim to estimate the heritability and genetic correlation attributable to the additive effects of common single-nucleotide polymorphisms (SNPs) for cancer at 13 anatomical sites. Methods: Between 2007 and 2014, the US National Cancer Institute has generated data from genome-wide association studies (GWAS) for 49 492 cancer case patients and 34 131 control patients. We apply novel mixed model methodology (GCTA) to this GWAS data to estimate the heritability of individual cancers, as well as the proportion of heritability attributable to cigarette smoking in smoking-related cancers, and the genetic correlation between pairs of cancers. Results: GWAS heritability was statistically significant at nearly all sites, with the estimates of array-based heritability, h(l)(2), on the liability threshold (LT) scale ranging from 0.05 to 0.38. Estimating the combined heritability of multiple smoking characteristics, we calculate that at least 24% (95% confidence interval [CI] = 14% to 37%) and 7% (95% CI = 4% to 11%) of the heritability for lung and bladder cancer, respectively, can be attributed to genetic determinants of smoking. Most pairs of cancers studied did not show evidence of strong genetic correlation. We found only four pairs of cancers with marginally statistically significant correlations, specifically kidney and testes (rho = 0.73, SE = 0.28), diffuse large B-cell lymphoma (DLBCL) and pediatric osteosarcoma (rho = 0.53, SE = 0.21), DLBCL and chronic lymphocytic leukemia (CLL) (rho = 0.51, SE = 0.18), and bladder and lung (rho = 0.35, SE = 0.14). Correlation analysis also indicates that the genetic architecture of lung cancer differs between a smoking population of European ancestry and a nonsmoking Asian population, allowing for the possibility that the genetic etiology for the same disease can vary by population and environmental exposures. Conclusion: Our results provide important insights into the genetic architecture of cancers and suggest new avenues for investigation.

This study explores the use of interventricular asynchrony (interVA) for optimizing cardiac resynchronization therapy (CRT), an idea emerging from a simple pathway model of conduction in the ventricles. Measurements were performed in six dogs with chronic left bundle branch block (LBBB) and in 29 patients of the Pacing Therapies for Congestive Heart Failure (PATH-CHF)-I study. In the dogs, intraventricular asynchrony (intraVA) was determined using left ventricular (LV) endocardial activation maps. In dogs and patients, the maximum rate of rise of LV pressure (LV dP/d tmax) and the pulse pressure (PP) and interVA [time delay between upslope of LV and right ventricular (RV) pressure curves] were measured during LV, RV, and biventricular (BiV) pacing with various atrioventricular (AV) delays. Measurements in the canine hearts supported the pathway model in that optimal resynchronization occurred at ∼50% reduction of intraVA and at an interVA value halfway that during LBBB and LV pacing. In patients with significant hemodynamic response during pacing ( n = 22), intrinsic interVA and interVA at peak improvement (interVAp) varied widely between patients (from −83 to −15 ms and from −42 to +31 ms, respectively). However, the model predicted individual interVAp accurately (SD of ±6 ms and ±12 ms for LV dP/d tmax and PP, respectively). At equal interVA, LV and BiV pacing produced equal hemodynamic response, but in 11 of 22 responders, BiV pacing reduced interVA insufficiently to reach the maximum hemodynamic response. LV pacing at short AV delay proved to result in better hemodynamics than predicted by the model, indicating that additional factors determine hemodynamics during LV preexcitation. Guided by a simple pathway model, interVA measurements accurately predict optimal hemodynamic performance in individual CRT patients.

Objectives The purpose of this study was to study the acute hemodynamic effect of left ventricular (LV) stimulation sites within a coronary vein. Background Access to LV stimulation sites for resynchronization therapy is achieved using specialized lead systems navigated through a coronary vein. The effects of stimulation in different coronary veins have been evaluated previously, but less is known about stimulation sites within a coronary vein. Methods Twenty-four patients (New York Heart Association functional class II–IV, age 59 ± 10 years, ejection fraction 21 ± 7%, QRS 166 ± 30 ms) were enrolled in the study. A novel over-the-wire lead system was used to access an anterior or lateral coronary vein. At each lead location, a randomized stimulation protocol was executed. Hemodynamic responses were evaluated using LV dP/dt max . Results The mean time to cannulate the coronary sinus and position the LV lead was 19 ± 30 minutes and 17 ± 18 minutes, respectively. Data from stimulation at two sites within a coronary vein were obtained in 19 patients (anterior vein 11; lateral vein 8). Of these patients, 14 (anterior vein 9; lateral vein 5) showed large improvement in dP/dt max (22%–25% in anterior vein, 37%–40% in lateral vein). Overall, there were no group differences in hemodynamic effects among different stimulation sites within a coronary vein, although significant variability among sites was observed in individuals. Conclusions Resynchronization therapy through a coronary vein improves acute hemodynamic function of heart failure patients with LV conduction disorder. There were no significant differences between basal and apical pacing sites for this group.

We tested whether biventricular resynchronization explains contractile function changes with univentricular and biventricular pacing in heart failure patients with varying magnitudes of baseline biventricular asynchrony. Thirty patients (New York Hospital Association class ≥ III, QRS duration ≥120 ms) were tested. Contractile function was measured by left ventricular maximum first derivative of pressure over time (dP/d tmax). Biventricular mechanical asynchrony was quantified by the normalized pressure-pressure (NPP) loop area formed by the cross-plot of right and left intraventricular pressure curves from each cardiac cycle. Any ventricular pacing increased dP/d tmax if it decreased baseline NPP loop area and almost always worsened dP/d tmax and asynchrony when baseline NPP loop area max and NPP loop area change depended on ventricular pacing site and timing relative to intrinsic activation. For similar NPP loop decreases, dP/d tmax increased 16% more with left and biventricular pacing compared with right ventricular pacing. In conclusion, right, left, or biventricular pacing can improve contractile function only in patients having sufficient baseline biventricular asynchrony. However, biventricular resynchronization is only one of the improvement mechanisms.

It has been estimated that about 320.000 to 400.000 patients in the USA alone are possible candidates to cardiac resynchronization therapy according to the recently published AHA/ACC/NASPE guidelines for pacing and the results of the COMPANION trial. The selection of the most suitable candidate for CRT/CRTD is a crucial issue, but still a matter of debate. A large variety of clinical, invasive and non-invasive criteria have been proposed for appropriately selecting candidates for CRT. However, in all the studies the parameters have been retrospectively identified and none has reported their results in the form of a multivariate regression model. We have now well characterized the patients in sinus rhythm who most likely benefit from this non-pharmacological approach. The fact that the COMPANION trial was able to single out a specific subgroup of heart failure patients that can be treated better than what was very short time ago best medical therapy validates the large body of research that investigators worldwide have created about this therapy. Finally, the concept that any patients that require ventricular pacing, who have heart failure class II/III or IV may benefit from receiving biventricular rather than right ventricular pacing as much as the other patients with more classical indication for CRT is still open to discussion and needs to be tested in a randomized multicenter trial.

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OBJECTIVES We sought to investigate the impact of six months of cardiac resynchronization therapy (CRT) on echocardiographic variables of left ventricular (LV) function. BACKGROUND Cardiac resynchronization therapy has recently been introduced as a new therapeutic modality in patients with advanced heart failure (HF) and conduction abnormalities. However, most studies have only investigated the early hemodynamic effects of CRT. METHODS Twenty-five patients (12 women and 13 men; 59.8 5.1 years old) with advanced HF caused by ischemic (n 7) or idiopathic dilated cardiomyopathy (n 18) and a prolonged QRS complex were analyzed. All patients underwent early hemodynamic testing with a randomized testing protocol; echocardiographic measurements were compared before implantation and after six months of CRT. RESULTS Left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD, respectively) were significantly reduced after six months (LVEDD from 71 10 to 68 11 mm, p 0.027; LVESD from 63 11 to 58 11 mm, p 0.007), as were LV end-diastolic and end-systolic volumes (LVEDV from 253 83 to 227 112 ml, p 0.017; LVESV from 202 79 to 174 101 ml, p 0.009). Ejection fraction was significantly increased (from 22 7% to 26 9%, p 0.03). “Nonresponders,” with regard to LV volume reduction, had significantly higher baseline LVEDV, compared with “responders” (351 52 vs. 234 74 ml, p 0.018). Overall, there was only mild mitral regurgitation at baseline, with a minor reduction by semiquantitative analysis. The results of early hemodynamic testing did not predict the volume response. CONCLUSIONS Cardiac resynchronization therapy may lead to a reduction in LV volumes in patients with advanced HF and conduction disturbances. Volume nonresponders have significantly higher baseline LVEDV. (J Am Coll Cardiol 2001;38:1957– 65) © 2001 by the American College of Cardiology

Background —Left ventricular or biventricular pacing/stimulation can acutely improve systolic function in patients with dilated cardiomyopathy (DCM) and intraventricular conduction delay by resynchronizing contraction. Most heart failure therapies directly enhancing systolic function do so while concomitantly increasing myocardial oxygen consumption (MVO 2 ). We hypothesized that pacing/stimulation, in contrast, incurs systolic benefits without raising energy demand. Methods and Results —Ten DCM patients with left bundle-branch block (ejection fraction 20±3%, QRS duration179±3 ms, mean±SEM) underwent cardiac catheterization to measure ventricular and aortic pressure, coronary blood flow, arterial–coronary sinus oxygen difference (ΔAVO 2 ), and MV̇O 2 . Data were measured under sinus rhythm or with left ventricular or biventricular pacing/stimulation at the same heart rate. These results were then contrasted to intravenous dobutamine (n=7) titrated to match systolic changes during LV pacing. Systolic function rose quickly and substantially from LV pacing (18±4% rise in arterial pulse pressure, which correlates with cardiac output, and 43±6% increase in dP/dt max ; both P 2 and MV̇O 2 declined −4±2% and −8±6.5%, respectively (both P max 37±6%, accompanied by a 22±11% rise in per-beat MV̇O 2 ( P Conclusions —Ventricular resynchronization by left ventricular or biventricular pacing/stimulation in DCM patients with left bundle-branch block acutely enhances systolic function while modestly lowering energy cost. This should prove valuable for treating DCM patients with basal dyssynchrony.

In the present work the effect of several bis(guanylhydrazones) on the growth of Helianthus tuberosus tuber explants was studied. Different aliphatic congeners of glyoxal bis(guanylhydrazone) were tested. Most of the compounds displayed an inhibitory effect on growth, and a correlation between the structure of the molecule and the inhibitory activity was observed. Experiments carried out with glyoxal bis(guanylhydrazone) and its congeners methyl-, ethylmethyl-, and methylpropylglyoxal bis(guanylhydrazones) show that as the total number of side chain carbon atoms in the molecule increases, the inhibitory potency also increases. A depletion of spermidine levels was also found in the explants treated with ethylmethylglyoxal bis(guanylhydrazone), which turned out to be one of the most potent growth inhibitors. The addition of spermidine caused a significant reversion of the antiproliferative action of glyoxal bis(guanylhydrazone). The effect of these compounds on spermidine uptake in protoplasts isolated from carrot phloem parenchyma was also investigated. Only a slight competition was found when antagonists were present at concentrations 20 times higher than the polyamine, thus suggesting that bis(guanylhydrazones) do not share, at least at low concentrations, the polyamine transport system in plant cells.Key Words. Bis(guanylhydrazones)-Carrot protoplasts-Growth-Helianthus tuberosus-Polyamines-Uptakehttp://link.springer-ny.com/link/service/journals/00344/bibs/18n1p39.html

Background —Previous studies of pacing therapy for dilated congestive heart failure (CHF) have not established the relative importance of pacing site, AV delay, and patient heterogeneity on outcome. These variables were compared by a novel technique that evaluated immediate changes in hemodynamic function during brief periods of atrial-synchronous ventricular pacing. Methods and Results —Twenty-seven CHF patients with severe left ventricular (LV) systolic dysfunction and LV conduction disorder were implanted with endocardial pacing leads in the right atrium and right ventricle (RV) and an epicardial lead on the LV and instrumented with micromanometer catheters in the LV, aorta, and RV. Patients in normal sinus rhythm were stimulated in the RV, LV, or both ventricles simultaneously (BV) at preselected AV delays in a repeating 5-paced/15-nonpaced beat sequence. Maximum LV pressure derivative (LV+dP/dt) and aortic pulse pressure (PP) changed immediately at pacing onset, increasing at a patient-specific optimal AV delay in 20 patients with wide surface QRS (180±22 ms) and decreasing at short AV delays in 5 patients with narrower QRS (128±12 ms) ( P P P Conclusions —In this population, CHF patients with sufficiently wide surface QRS benefit from atrial-synchronous ventricular pacing, LV stimulation is required for maximum acute benefit, and the maximum benefit at any site occurs with a patient-specific AV delay.

Despite increasing evidence of hemodynamic benefit and long-term improvement in clinical status of congestive heart failure (CHF) patients with left ventricular and biventricular pacing, the risks and technical limitations of placing a permanent left ventricular pacing lead have prevented widespread clinical adoption of this therapy. Results of this and other recent investigations suggest it is necessary to target specific sites on the left ventricle to maximize hemodynamic benefit. However, limitations and variations of coronary vein anatomy, as well as patient safety, lead dislodgement, pacing thresholds, lead handling, and ease-of-use issues, present technical challenges for current transvenous permanent pacing lead designs. However, a new transvenous lead system based on an over-the-wire design appears to solve many of these problems and has proved feasible in acute clinical studies.

For his PhD. thesis, Zijderveld (1975) studied the paleomagnetism of the Permian Esterel rocks (southern France). High-quality thermal and alternating-field demagnetization diagrams were interpreted to determine the direction of the characteristic natural magnetization. For the Esterel volcanics, a mean direction of Dec = 206.5°, Inc = −23°, α95 = 5.7°, k = 112 was found for this magnetization. The dispersion in this mean is remarkably low. Only the declination of the Reyran Rhyolite in the Reyran River quarry clearly deviated from this mean. This deviating direction is not found in our samples, taken at the same site. As many faults occur in this quarry, it is suggested that Zijderveld sampled this rhyolite on a small rotated block. To verify whether the small dispersion in the mean paleomagnetic direction of the Esterel rocks has a geomagnetic or a rock-magnetic origin, two conglomerate tests were carried out. One of these might be interpreted as positive. The results of the other conglomerate test (Agay Formation) are ambiguous: four of the six measured boulders show directions close to the mean paleomagnetic direction of the Esterel rocks. Rock-magnetic measurements show that the remanence is carried by a magnetite and a hematite fraction. The low dispersion in the paleomagnetic directions, the conglomerate tests, and hematite as remanence carrier suggest that the characteristic remanence in the Esterel volcanics was not instantaneously acquired during cooling, but might be affected by remagnetization due to weathering.

Cardiac Resynchronization Therapy. Background: A significant proportion of patients with dilated cardiomyopathy and left bundle branch block (LBBB) do not respond to cardiac resynchronization therapy (CRT). The purpose ofthis study was to investigate whether the electromechanical properties of the myocardium would predict acute hemodynamic improvement during left ventricular (LV) pacing. Methods and Results: We studied 10 patients with idiopathic dilated cardiomyopathy and LBBB (ejection fraction (EF): 27% ′ 7%; QRS duration: 166 ′ 16 msec) using three-dimensional electromechanical endocardial mapping technique to assess endocardial activation time (Endo-AT), unipolar voltage, and local linear shortening during sinus rhythm. LV stimulation was performed in VDD mode at live different sites and three atrioventricular delays within the coronary sinus. LV + dP/dt m a x changes from baseline were measured during LV stimulation at each site (%ΔdP/dt m a x ). There was no significant relationship between maximum % ΔdP/dt m a x during LV stimulation at the best coronary sinus site and LV EF, baseline LV + dP/dt m a x , total LV Endo-AT, baseline QRS duration nor changes in QRS duration during LV pacing. However, the maximum %ΔdP/dt m a x was significantly positively correlated with percentage area of late Endo-AT (r = 0.97, P 20% of LV area with late Endo-AT and >30% of preserved LV myocardium had five times better acute hemodynamic response with LV stimulation. Multivariate analysis showed that only percentage area of late Endo-AT was independently correlated with %ΔdP/dt m a x (P < 0.05). Conclusion: The presence of a larger amount of LV area with late Endo-AT and preserved LV myocardium measured by electromechanical mapping could identify patients who have better acute improvement in systolic performance during LV stimulation.

Hypertrophic pyloric stenosis (IHPS) is the most common abdominal abnormality requiring surgery in infants. It occurs due to the hypertrophic and hyperplasia of the muscular layers of the pyloric. The usual age of clinical presentation is about three weeks of life. The most important symptom is non bilious emesis, intermittent or after each feeding. From march 1996 to June 2001, 21 infants, 20 males and 1 female, were subjected to ultrasonographic, radiographic exams and after diagnosis to the pyloromyotomy extramucosa. Ultrasonography was the study of choice used to identify hypertrophic pyloric stenosis; the markers to analyse were the length and the overall diameter of the pyloric canal and the muscle thickness of the wall. The results showed that a length of the pyloric canal 20 +/- 6 mm, a diameter 13.6 +/- 2.5 mm and a muscle thickness 4.1 +/- 1 mm are diagnostics for hypertrophic pyloric stenosis.

It has been estimated that about 320,000 to 400,000 patients in the USA alone are possible candidates to cardiac resynchronization therapy according to the recently published AHA/ACC/NASPE guidelines for pacing and the results of the COMPANION trial. The selection of the most suitable candidate for CRT/CRTD is a crucial issue, but still a matter of debate. A large variety of clinical, invasive and non-invasive criteria have been proposed for appropriately selecting candidates for CRT. However, in all the studies the parameters have been retrospectively identified and none has reported their results in the form of a multivariate regression model. We have now well characterized the patients in sinus rhythm who most likely benefit from this non-pharmacological approach. The fact that the COMPANION trial was able to single out a specific subgroup of heart failure patients that can be treated better than what was very short time ago best medical therapy validates the large body of research that investigators worldwide have created about this therapy. Finally, the concept that any patients that require ventricular pacing, who have heart failure class II/III or IV may benefit from receiving biventricular rather than right ventricular pacing as much as the other patients with more classical indication for CRT is still open to discussion and needs to be tested in a randomized multicenter trial.

Cardiac resynchronization therapy (CRT) is a new non-pharmacological option for patients with advanced heart failure and ventricular conduction delay. Four randomized prospective studies have provided evidence that CRT increases exercise capacity, improves functional class and quality of life. There is also increasing evidence that CRT may trigger an inverse remodeling process leading to reduction of ventricular diameter and eventually of the atrial size. The pathophysiological mechanism throughout CRT may promote inverse remodeling is: (1) reduction of systolic and diastolic mitral regurgitation; (2) reduction of sympathetic/parasympathetic imbalance as well as reduction of neurohumoral activation due to increased systolic blood pressure and improved filling time; (3) reduction of regional wall stress. The structural changes taking place during CRT are directly related to continuous pacing, because lack of pacing immediately shows the new onset of remodeling. The duration of the reported changes of ventricular diameter is still unknown, and it is also unknown whether such reverse remodeling process of the ventricle and of the atria will lead to a reduction of cardiac death and incidence of ventricular arrhythmias.

"Graves' disease" is an autoimmune pathology and is the most important cause of hyperthyroidism in children and adolescents. The treatment for this disease is controversial; there are three different options: synthetic antithyroid drugs, ablation of the thyroid gland with I 131 or surgery. Our study reports the clinical and therapeutic aspects and long-term results of 27 patients (= 18 years old) treated with total thyroidectomy or "near-total" thyroidectomy from 1975 to August 2001. Antithyroid drugs represent the preliminary treatment of choice. For a long time in the past therapy with radioactive iodine was not recommended; now it represents an efficiently therapy with low morbility. Surgical treatment is suitable when a young patient presents a considerable enlargement of the thyroid gland or when antithyroid medical treatment does not achieve a good control of the disease, or when rapid control of hyperthyroidism is necessary. The surgical treatment can be a total thyroidectomy or a "near-total" thyroidectomy. The first is the best choice for us, because it has a low risk of relapse and a major efficacy in the ophthalmopathy.

Background— Biventricular (BiV) and left ventricular (LV) pacing similarly augment systolic function in left bundle-branch block (LBBB)-failing hearts despite different electrical activation. We tested whether electrical synchrony is required to achieve mechanical synchronization and functional benefit from pacing. Methods and Results— Epicardial mapping, tagged MRI, and hemodynamics were obtained in dogs with LBBB-failing hearts during right atrial, LV, and BiV stimulation. BiV and LV both significantly improved chamber hemodynamics (eg, 25% increase in dP/dt max and aortic pulse pressure) compared with atrial pacing-LBBB, and this improvement correlated with mechanical resynchronization. Electrical dispersion, however, decreased 13% with BiV but increased 23% with LV pacing ( P Conclusion— Improved mechanical synchrony and function do not require electrical synchrony. Mechanical coordination plays the dominant role in global systolic improvement with either pacing approach.

Minimally invasive video-assisted (MIVA) surgery of the thyroid is now widely accepted by endocrinel surgeons, especially in adult age. This report describes indications, limits, technical aspects and results of MIVA in 10 young patients (mean age 16 years, range 11-18) enrolled in a study of 213 patients (mean age 45 years, range 11-81) operated with this technique, from October 1998 to August 2001, in the Department of Surgery at the University of Pisa. Young patients were submitted to surgery: 8 lobectomies (6 for microfollicular lesions and 2 for adenomas functionally autonomous) and 2 total thyroidectomies for papillary carcinoma. No case has been converted in "open" surgery and no post-operatory complications have been observed. Elective indications of MIVA are the volume of the nodule and the istological type. This technique cannot be performed in voluminous goiters, in medullary carcinomas and in scarcely differentiated carcinomas. Minimally invasive video-assisted surgery of the thyroid, in our experience, represents a reliable technique also in pediatric age.

Ventricular dysfunction is a hallmark of heart failure, and is often linked to ventricular dilatation and ventricular conduction delays. Recent studies have demonstrated that systolic function can be improved in patients with left bundle branch block by pre-exciting the site of late activation, usually the left ventricular free wall. Furthermore, it has been recently reported that this improvement is associated with a decrease in myocardial oxygen consumption. We hypothesize that the pre-excitation of the region covered by the blocked bundle acts as an "electrical bypass," resynchronizing the contraction of the septum and the left ventricular free wall. In addition, optimization of the electronic atrioventricular delay allows the simultaneous resynchronization of the atrioventricular contractions, and minimization of diastolic mitral regurgitation. Systolic mitral regurgitation may also be reduced by removing the geometric distortion introduced by the left bundle branch block. The recently reported positive outcome of the PATH-CHF I controlled trial reinforces that the positive acute and chronic results that have been reported up to now may translate into long-term clinical benefit for patients with heart failure and conduction defects. Larger studies are needed to confirm these initial results and to establish the impact of this new therapeutic modality on morbidity and mortality. (c)2000 by CHF, Inc.

tests is frequent in patients with heart failure. 4 An objective measurement of functional capacity that is continuous, unbiased, and based on activities of daily living would be more useful clinically. In this sense, continuous collection of accelerometer signals, which are currently used in pacemakers and implantable cardioverter-defibrillators only for modulating heart rate during exercise, might also be used for monitoring patient activity. This study reports on a new tool for measuring daily physical activity of heart failure patients, namely, the activity log index (ALI), which quantifies body movement based on data derived from

Positive responses to left (LV) and biventricular (BV) stimulation observed in heart failure patients with left bundle branch block (LBBB) suggest a possible mechanism of LV resynchronization. An anesthetized canine LBBB model was developed using radio frequency ablation. Before and after ablation, LV pressure derivative over time (dP/d t) and aortic pulse pressure (PP) were assessed during normal sinus rhythm with right ventricle (RV), LV, or BV stimulation combined with four atrioventricular delays in six dogs. In three more dogs, M-mode echocardiograms of septal and LV posterior wall motion were obtained before and after LBBB and during LV stimulation. LBBB caused QRS widening and hemodynamics deterioration. Before ablation, stimulation alone worsened LV dP/d t and PP. After ablation, LV and BV stimulation maximally increased LV dP/d t by 16% and PP by 7% ( P < 0.001), whereas little improvement was observed during RV stimulation. M-mode echocardiogram showed that LBBB resulted in a paradoxical septal wall motion that was corrected by LV stimulation. In conclusion, LV and BV stimulation improved cardiac function in a canine LBBB model via resynchronization of LV excitation and contraction.