Cerebral vasculitis in severe Kawasaki disease: early detection by magnetic resonance imaging and good outcome after intensive treatment

Kawasaki disease is an acute vasculitis, that has a classic complication of acquired coronary artery aneurysm. Severe forms with multi‐organ involvement or neurological dysfunction are rare. Cerebral vascular involvement has been related to large‐vessel injury or cardioembolism, leading to focal brain infarction. A 4‐year‐old female presented with unusual, rapidly catastrophic Kawasaki disease with refractory shock, acute renal failure, and coma, requiring intensive haemodynamic management. The observation of diffuse micro‐haemorrhages (T2*‐weighted sequence) associated with white matter injury on brain magnetic resonance imaging (MRI) pointed towards lesions of the medium/small blood vessels. Cerebral vasculitis was suspected and the immunosuppressive treatment was increased Subsequently, the patient’s recovery was rapid. On follow‐up severe, bilateral vitritis was evident and surgery improved visual outcome. Early recognition of severe or unusual forms of Kawasaki disease could lead to more favourable outcome using appropriate treatment strategies. Diffuse cerebral micro‐haemorrhages on T2* brain MRI sequences might be a key sign for the diagnosis of medium or small cerebral vessel involvement.     

Ultrasound guided internal jugular vein access in children and infant: A meta‐analysis of published studies

Introduction: Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of internal jugular vein (IJV) access has been shown to decrease failure rate and complications related to this invasive procedure. The goal of the present study was to perform a systematic review of the advantages of UPG over anatomical landmarks (AL) during IJV access in children and infants. Material and methods: A comprehensive literature search was conducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I² statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the experience of practitioners. Results: Literature found five articles. Most of the patients were cardiac surgery patients. In comparison with AL, UPG had no effect on IJV access failure rate (OR = 0.28 [0.05, 1.47], I² = 75%, P = 0.003), the rate of carotid artery puncture (OR = 0.32 [0.06, 1.62], I² = 68%, P = 0.01), haematoma, haemothorax, or pneumothorax occurrence (OR = 0.40 [0.14, 1.13], I² = 17%, P = 0.30, OR = 0.72, OR = 0.81 [0.18, 3.73], I² = 0%, P = 0.94, respectively) and time to IJV access and haemothorax/pneumothorax occurrence. Subgroup analysis found an efficacy of ultrasound when used by novice operators or during intraoperative use. Discussion: This current meta‐analysis does not found the utility of ultrasound during IJV access in children and infants in increasing the success rate and in decreasing complications.     

Rapid determination and NMR assignments of antiparallel sheets and helices of a scorpion and a cobra toxin

An NMR method is described which should provide a rapid means for determining and assigning antiparallel sheets and helices in small proteins. It begins by locating apparent NOESY crosspeaks which suggest the presence of the secondary structure; this is followed by searches for MCD patterns (Englander & Wand (1987) Biochemistry 22, 5953) which are characteristic of these structures. As a result, only spin-systems of the amino acids within the secondary structure need to be defined. A triple-stranded, antiparallel sheet and a helix have been found and assigned for both α-cobratoxin and the scorpion toxin AaH III.     

Gene Expression of the Natriuretic Peptide System in Atrial Tissue of Patients with Paroxysmal and Persistent Atrial Fibrillation

INTRODUCTION: Circulating cardiac natriuretic peptides play an important role in maintaining volume homeostasis, especially during conditions affecting hemodynamics. During atrial fibrillation (AF), levels of plasma atrial natriuretic peptide (ANP) becomes elevated. The aim of this study was to gather information about gene expression of the natriuretic peptide system on the atrial level in patients with AF. METHODS AND RESULTS: Right atrial appendages of 36 patients with either paroxysmal or persistent AF were compared with 36 case matched controls in sinus rhythm for mRNA expression of pro- atrial natriuretic peptide (pro-ANP), pro-brain natriuretic peptide (pro-BNP), and their natriuretic peptide receptor type-A (NPR-A). We investigated patients without (n = 36) and with (n = 36) valvular disease. Persistent AF was associated with higher mRNA expression of pro-BNP (+66%, P = 0.04, in patients without valvular disease, and +69%, P < 0.01, in patients with valvular disease) and lower mRNA expression of NPR-A (-58%, P = 0.02, in patients without valvular disease, and -62 %, P < 0.01, in patients with valvular disease). The mRNA content of pro-ANP was only increased in patients with valvular disease (+12%, P = 0.03). No changes were observed in patients with paroxysmal AF. CONCLUSION: This study demonstrates that persistent, but not paroxysmal, AF induces alterations in gene expression of pro-BNP and NPR-A on the atrial level. Although AF generally is associated with an increase of plasma ANP level, a change in mRNA content of pro-ANP is only observed in the presence of concomitant valvular disease and is of minor magnitude.     

Contact‐Force Catheters: Efficacy Versus Safety? Case Report of 2 Atrioesophageal Fistulae

Contact‐force (CF) catheters appear to be more effective compared to standard ablation catheters for complex radiofrequency ablation including atrial fibrillation (AF) ablation when optimal CF >10 g is achieved. Some have suggested that this technology could also improve procedural safety. We report 2 cases of atrioesophageal fistulae (AEF), a rare but catastrophic complication of AF ablation. These are to our knowledge the first cases of AEF described after using CF catheters.     

Atrial Fibrillation Ablation by Aortic Retrograde Approach Using a Magnetic Navigation System

AF Ablation by Aortic Retrograde Approach Using an MNS . Stereotaxis remote magnetic navigation system (MNS) (St. Louis, MO, USA) is a new technology with applications in the field of catheter ablation of cardiac arrhythmias. We report a case where the Stereotaxis MNS was successfully used to perform pulmonary vein isolation by a retrograde approach in a patient with atrial fibrillation in whom transseptal access was impossible. (J Cardiovasc Electrophysiol, Vol. 21, pp. 455–457, April 2010)     

Trends in the use of hormone replacement therapy in eastern France between 1986 and 1993

Background: In 1986, 8% of the women examined at a centre forpreventive medicine in eastern France used hormone replacementtherapy (HRT). Our objective in 1993 was to re-examine thisprevalence and to analyse the trends in HRT use and the factorsthat might have influenced changes. Methods: The 1986 populationconsisted, by coincidence, of 1,986 post-menopausal women aged45–55 years and the 1993 population included 1,576 suchwomen. The women in each period were compared for various characteristics,which were determined from questionnaire responses. In addition,current HRT users were compared with non-users for both periods.The influence of time and of the women's characteristics onthe changes in the prevalence of HRT use were analysed. Results:In both years, users were more frequently born in France, hada higher level of education and were more often employed thannon-users. Between 1986 and 1993 the prevalence of HRT use rosefrom 8% to 38%. This marked increase seemed mainly associatedwith the time period. The increase in HRT use across subgroupsshowed no evidence of heterogeneity. While the use of HRT increased,it remained more common among women who were younger, better-educatedand born in France. Conclusion: The trend towards a high prevalenceof HRT use makes it all the more important to understand asthoroughly as possible the effects of HRT, both protective (e.g.for cardiovascular risk) and negative (e.g. the possible riskof breast cancer).     

Subjective symptoms in idiopathic hypersomnia: beyond excessive sleepiness

Patients with idiopathic hypersomnia never feel fully alert despite a normal or long sleep night. The spectrum of the symptoms is insufficiently studied. We interviewed 62 consecutive patients with idiopathic hypersomnia (with a mean sleep latency lower than 8 min or a sleep time longer than 11 h) and 50 healthy controls using a questionnaire on sleep, awakening, sleepiness, alertness and cognitive, psychological and functional problems during daily life conditions. Patients slept 3 h more on weekends, holidays and in the sleep unit than on working days. In the morning, the patients needed somebody to wake them, or to be stressed, while routine, light, alarm clocks and motivation were inefficient. Three‐quarters of the patients did not feel refreshed after short naps. During the daytime, their alertness was modulated by the same external conditions as controls, but they felt more sedated in darkness, in a quiet environment, when listening to music or conversation. Being hyperactive helped them more than controls to resist sleepiness. They were more frequently evening‐type and more alert in the evening than in the morning. The patients were able to focus only for 1 h (versus 4 h in the controls). They complained of attention and memory deficit. Half of them had problems regulating their body temperature and were near‐sighted. Mental fatigability, dependence on other people for awakening them, and a reduced benefit from usually alerting conditions (except being hyperactive or stressed) seem to be more specific of the daily problems of patients with idiopathic hypersomnia than daytime sleepiness.