Wide QRS complex tachycardia in a patient after inferior myocardial infarction and CABG -- the role of electrophysiological study and RF ablation

We present a case of 53-year-old patient who experienced paroxysms of wide QRS complex tachycardia at a rate of 150 bpm and LBBB morphology 6 years after inferior myocardial infarction and CABG. Anamnesis and morphology of tachycardia could suggest ventricular tachycardia. However during electrophysiological study we observed AVRT with LBBB and "regularly irregular" AVRT with normal QRS complex and changing entrance to the AV node (through slow and fast pathway). In this paper we present our approach and try to explain why the tachycardia using concealed bypass tract appeared so late in life.     

Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study: Common Genetic Variants in GCK and TCF7L2 Are Associated With Fasting and Postchallenge Glucose Levels in Pregnancy and With the New Consensus Definition of Gestational Diabetes Mellitus From the International Association of Diabetes and Pregnancy Study Groups

OBJECTIVE

Common genetic variants in GCK and TCF7L2 are associated with higher fasting glucose and type 2 diabetes in nonpregnant populations. However, their associations with glucose levels from oral glucose tolerance tests (OGTTs) in pregnancy have not been assessed in a large sample. We hypothesized that these variants are associated with quantitative measures of glycemia in pregnancy.

RESEARCH DESIGN AND METHODS

We analyzed the associations between variants rs1799884 (GCK) and rs7903146 (TCF7L2) and OGTT outcomes at 24–32 weeks'' gestation in 3,811 mothers of European (U.K. and Australia) and 1,706 mothers of Asian (Thailand) ancestry from the HAPO cohort. We also tested associations with offspring birth anthropometrics.

RESULTS

The maternal GCK variant was associated with higher fasting glucose in Europeans (P = 0.001) and Thais (P < 0.0001), 1-h glucose in Europeans (P = 0.001), and 2-h glucose in Thais (P = 0.005). It was also associated with higher European offspring birth weight, fat mass, and skinfold thicknesses (P < 0.05). The TCF7L2 variant was associated with all three maternal glucose outcomes (P = 0.03, P < 0.0001, and P < 0.0001 for fasting and 1-h and 2-h glucose, respectively) in the Europeans but not in the Thais (P > 0.05). In both populations, both variants were associated with higher odds of gestational diabetes mellitus according to the new International Association of Diabetes and Pregnancy Study Groups recommendations (P = 0.001–0.08).

CONCLUSIONS

Maternal GCK and TCF7L2 variants are associated with glucose levels known to carry an increased risk of adverse pregnancy outcome in women without overt diabetes. Further studies will be important to determine the variance in maternal glucose explained by all known genetic variants.Maternal glycemia in pregnancy is associated with adverse pregnancy outcomes including birth weight >90th percentile, delivery by cesarean section, neonatal hypoglycemia, and fetal hyperinsulinemia (1). These associations occur across the full range of maternal glucose levels below those classified as overt diabetes.In healthy, nondiabetic, nonpregnant populations, approximately one-third of the variation in fasting glucose is genetic (2), and common genetic variants at multiple loci are now robustly associated with fasting glucose (3–10) and with type 2 diabetes and related glycemic traits (11–18). Thus, genetic factors are likely to contribute to variation in glucose levels in pregnancy. However, these variants have not been examined extensively in large studies of pregnant women.Studies of birth weight in Europeans have provided indirect evidence that two common genetic variants influence maternal glycemia in pregnancy. The T-allele of the rs1799884 variant in the GCK gene is associated with higher fasting glucose in the general population (4) and with type 2 diabetes (10). Pregnant women who carry this allele give birth to babies that are, on average, 32 g (95% CI 11–53) heavier at birth (4). Similarly, each additional T-allele of rs7903146 in the TCF7L2 gene—which is associated with reduced β-cell function, raised fasting glucose, and type 2 diabetes (10,13,19)—is also associated with a 30-g (95% CI 15–45) higher offspring birth weight when carried by the mother (20). We hypothesize that these associations with birth weight reflect higher levels of maternal glucose, which result in greater fetal insulin secretion and a consequent increase in fetal size at birth (21).There is some evidence from small studies that the GCK and TCF7L2 variants are associated with fasting glucose in pregnancy or gestational diabetes mellitus. The GCK variant was associated with higher fasting glucose in 755 European pregnant women from the U.K. (22) and with gestational diabetes mellitus in a Scandinavian sample (23). Variation at the TCF7L2 locus was not associated with fasting glucose in 921 European pregnant women (20) but was associated with gestational diabetes mellitus in Scandinavian (24,25), Korean (26), and Mexican-American (27) samples.The large sample size and detailed pregnancy and birth phenotype data available in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study provide a unique opportunity to investigate more thoroughly the associations of the GCK and TCF7L2 variants with maternal glycemia, as measured in an oral glucose tolerance test (OGTT), during pregnancy as well as fetal size at birth and body composition. We used OGTT results from 5,517 pregnant women of European and South East Asian ancestry to assess associations both with quantitative measures of maternal glucose and with the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations for the diagnosis of gestational diabetes mellitus (28).     

Spatiotemporal mapping of sex differences during attentional processing

Functional neuroimaging studies have increasingly aimed at approximating neural substrates of human cognitive sex differences elicited by visuospatial challenge. It has been suggested that females and males use different behaviorally relevant neurocognitive strategies. In females, greater right prefrontal cortex activation has been found in several studies. The spatiotemporal dynamics of neural events associated with these sex differences is still unclear. We studied 22 female and 22 male participants matched for age, education, and nicotine with 29‐channel‐electroencephalogram recorded under a visual selective attention paradigm, the Attention Network Test. Visual event‐related potentials (ERP) were topographically analyzed and neuroelectric sources were estimated. In absence of behavioral differences, ERP analysis revealed a novel frontal‐occipital second peak of visual N100 that was significantly increased in females relative to males. Further, in females exclusively, a corresponding central ERP component at around 220 ms was found; here, a strong correlation between stimulus salience and sex difference of the central ERP component amplitude was observed. Subsequent source analysis revealed increased cortical current densities in right rostral prefrontal (BA 10) and occipital cortex (BA 19) in female subjects. This is the first study to report on a tripartite association between sex differences in ERPs, visual stimulus salience, and right prefrontal cortex activation during attentional processing. Hum Brain Mapp 2009. © 2009 Wiley‐Liss, Inc.     

Nutritional rickets: report of four cases diagnosed at orthopaedic evaluation

Nutritional rickets, the classic form of vitamin D-deficiency rickets, is rarely seen in the setting of modern medicine. We report four cases of nutritional rickets diagnosed at the time of orthopedic evaluation at our institutions during a 3-year period. All patients were referred by their pediatricians for evaluation of bowlegs. All children lived in a northern climate. Three were black and one was white. Prolonged breast-feeding and an unusual diet were identified as the underlying cause in our cases. Genu varum, seen in the setting of relative short stature and low weight, with a consistent social history, should raise the suspicion for nutritional rickets. The continued prevalence of this disease entity must be recognized in both the primary care and the orthopedic surgery setting. Vitamin D supplementation and enhanced sunlight exposure serve as effective prophylaxis and treatment of this disease.     

HEALTH C.H.I.P.s: opportunistic community use of computerized health information programs

Computerized health information programs have been shown to have potential to improve knowledge, attitudes and behavior. However, relatively little is known regarding their capacity to engage the public for opportunistic, spontaneous use in community settings. Two studies were undertaken to provide insight to this practical issue. An intercept survey of adults from a shopping center where a computer kiosk had been located for 7 months was undertaken to investigate exposure to, attention to, use and acceptability of kiosks. A total of 99.7% of participants were exposed to the kiosk, 77.4% of these noticed it and 20.8% of these used it. Program acceptability was high; the most common barriers to use related to time constraints and disinterest. A utilization study was then undertaken to describe program utilization in greater detail, with kiosks installed in 18 community settings over 1 year. These were used 57,064 times (19.4 uses per kiosk per day). Additional data described demography of users, preferred topics selected, preferred formats and presentation styles, and a comparison of use across different community settings. Both studies provide insight to practical application of this health education strategy, indicating that is has substantial capacity to engage people for opportunistic use in community settings.     

Higher prevalence of antibodies to Borrelia burgdorferi in psychiatric patients than in healthy subjects

OBJECTIVE: Borrelia burgdorferi infection can affect the CNS and mimic psychiatric disorders. It is not known whether Borrelia burgdorferi contributes to overall psychiatric morbidity. The authors compared the prevalence of antibodies to Borrelia burgdorferi in groups of psychiatric patients and healthy subjects to find out whether there is an association between this infection and psychiatric morbidity. METHOD: Between 1995 and 1999 the authors screened for antibodies to Borrelia burgdorferi in 926 psychiatric patients consecutively admitted to Prague Psychiatric Center. They compared the results of this screening with findings from 884 consecutive healthy subjects who took part in an epidemiological survey of antibodies to Borrelia burgdorferi in the general population of the Czech Republic. Sera were tested by means of enzyme-linked immunosorbent assay. Circulating immune complexes were isolated by polyethylene glycol precipitation. To control for potential confounders, the two groups of patients and healthy subjects were matched according to gender and age. Results were obtained in a sample of 499 matched pairs. RESULTS: Among the matched pairs, 166 (33%) of the psychiatric patients and 94 (19%) of the healthy comparison subjects were seropositive in at least one of the four assays. CONCLUSIONS: These findings support the hypothesis that there is an association between Borrelia burgdorferi infection and psychiatric morbidity. In countries where this infection is endemic, a proportion of psychiatric inpatients may be suffering from neuropathogenic effects of Borrelia burgdorferi.     

Clinical value of monitoring eosinophil activity in asthma.

To evaluate the use of eosinophil cationic protein (ECP) in monitoring disease activity in childhood asthma, serum ECP in 175 asthmatic children was assessed. Forty five patients with cystic fibrosis, 23 with lower respiratory tract infections (LRTI), and 87 healthy children were used as controls. Serum ECP concentrations (34.3 micrograms/l v 9.8 micrograms/l) were significantly higher in children with bronchial asthma than in healthy control subjects. In symptomatic patients with asthma serum ECP concentrations were increased compared with those from asymptomatic patients (40.2 micrograms/l v 14.4 micrograms/l), irrespective of treatment modalities (that is steroids, beta 2 agonists, or sodium cromoglycate). Moreover, atopy and infection appeared to be factors enhancing eosinophil activity in bronchial asthma as measured by serum ECP (58.4 micrograms/l v 36.8 micrograms/l and 68.8 micrograms/l v 42.2 micrograms/l, respectively). In a longitudinal trial, antiasthmatic treatment modalities (that is steroids) reduced serum ECP within four weeks (42.2 micrograms/l v 19.0 micrograms/l). In conclusion, the data indicate that (1) eosinophils also play a central part in childhood asthma; (2) serum concentrations of ECP in children with bronchial asthma are related to the disease severity and may thus be used for monitoring inflammation in childhood asthma; (3) eosinophil activity appears to be enhanced by atopy and infection; and (4) longitudinal measurements of serum ECP concentrations may be useful for optimising anti-inflammatory treatment in children with bronchial asthma.     

Clinical value of monitoring eosinophil activity in asthma

The prevalence and clinical features of migraine headache and abdominal migraine were studied in the well defined population of Aberdeen schoolchildren. Ten per cent of all children (2165) aged 5-15 years were given a questionnaire inquiring, among other symptoms, about the history of headache and abdominal pain over the past year. A total of 1754 children (81%) responded. Children with at least two episodes of severe headache and/or sever abdominal pain, attributed by the parents either to unknown causes or to migraine, were invited to attend for clinical interview and examination. After interview, 159 children fulfilled the International Headache Society's criteria for the diagnosis of migraine and 58 children had abdominal migraine giving estimated prevalence rates of 10.6% and 4.1% respectively. Children with abdominal migraine had demographic and social characteristics similar to those of children with migraine. They also had similar patterns of associated recurrent painful conditions, trigger and relieving factors, and associated symptoms during attacks. The similarities between the two conditions are so close as to suggest that they have a common pathogenesis.