Prevalence and prognostic significance of atrial arrhythmias after orthotopic cardiac transplantation

Objectives. We studied the duration and prognostic significance of atrial arrhythmias in the denervated transplanted heart, specifically the occurrence of atrial fibrillation in the absence of vagal modulation.

Background. Substantial animal data indicate that vagally induced dispersion of atrial refractoriness plays a central role in the induction and maintenance of atrial fibrillation.

Methods. We studied the occurrence of atrial arrhythmias in the denervated hearts of 88 consecutive orthotopic transplantations in 85 patients by means of continuous telemetry and all available electrocardiographic tracings.

Results. Fifty percent of recipients (44 of 88) developed at least one atrial arrhythmia. Atrial fibrillation occurred 23 times (21 recipients), atrial flutter 39 times (26 recipients), ectopic atrial tachycardia 3 times (3 recipients) and supraventricular tachycardia 18 times (11 recipients). The number of atrial fibrillation and atrial flutter episodes did not differ (23 vs. 39, p = 0.072), but the fibrillation (37.0 ± 10 vs. 6.6 ± 3.6 h, p = 0.014). Atrial fibrillation was associated with an increased risk of subsequent death (10 of 21 recipients with vs. 15 of 67 without atrial fibrillation, risk ratio 3.15 ± 0.18, p = 0.005 by Cox proportional hazards model). All 5 recipients who developed “late” atrial fibrillation (>2 weeks after transplantation) died versus 5 of 16 who developed atrial fibrillation within the first 2 weeks (p = 0.007). Causes of death included rejection (three recipients), allograft failure (two recipients), infection (three recipients) and multiorgan failure (two recipients). Atrial fibrillation was not associated with age, gender, ischemic time, reason for transplantation, echocardiographic variables, invasive hemodynamic variables or biopsy grade. Mean time from atrial arrhythmia to echocardiography was 2.7 ± 3.3 days; that to biopsy was 4.8 ± 6.3 days. Atrial flutter was not associated with subsequent death. Only 7 (15.9%) of 44 recipients demonstrated moderate or severe allograft rejection at the time of the arrhythmia.

Conclusions. Atrial arrhythmias occur frequently in the denervated transplanted heart, often in the absence of significant rejection. Late atrial fibrillation may be associated with an increased all-cause mortality.     

A comparison of a generic and oral health–specific measure in assessing the impact of early childhood caries on quality of life

Lee GHM, McGrath C, Yiu CKY, King NM. A comparison of a generic and oral health–specific measure in assessing the impact of early childhood caries on quality of life. Community Dent Oral Epidemiol 2010; 38: 333–339. © 2010 John Wiley & Sons A/S Abstract – Objectives: The aim of this study was to compare the performance of a generic health‐related quality‐of‐life measure, the Pediatric Quality of Life Inventory Version 4.0 (PedsQL? 4.0) and an oral health–specific quality‐of‐life measure, the Early Childhood Oral Health Impact Scale (ECOHIS) in assessing the impact of severe early childhood caries (S‐ECC) on the children’s quality of life. Methods: A trained and calibrated examiner conducted a clinical oral assessment of 111 children (mean age: 49 ± 12 months): 64 of whom were categorized as having S‐ECC and 47 as being caries‐free. Primary caregivers completed a Chinese version of the PedsQL? 4.0 and the ECOHIS. Clinical examinations were conducted blind of the parental assessments. Results: The ECOHIS scores were significantly higher for the S‐ECC group than for the caries‐free group (P ≤ 0.001). No significant difference was found between the PedsQL? 4.0 scores in relation to caries status, except for the subscale of physical functioning (P = 0.04). Correlation of caries status with the ECOHIS scores was strong (r = 0.66; P < 0.01). No significant correlation was found between PedsQL? 4.0 scores and caries status (r = 0.02; P > 0.05). Conclusions: The oral health–specific measure, ECOHIS, shows better discriminant property between children with S‐ECC and caries‐free children than the generic measure, PedsQL? 4.0. The ECOHIS appears more sensitive than PedsQL? 4.0 in assessing the impact of dental caries on the life quality of preschool children.     

Hand‐foot‐skin reaction related to use of the multikinase inhibitor sorafenib and hard orthotics

Hand‐foot‐skin reaction is a distinct clinical condition arising in association with the use of multikinase inhibitors, including sorafenib. Because multikinase inhibitors are increasingly being used in children with cancer, recognition of this previously unfamiliar condition is of importance to pediatric dermatologists. We describe the diagnosis and successful treatment of a case of hand‐foot‐skin reaction in a child taking sorafenib for an unresectable desmoid tumor.     

Constitutional and mosaic large NF1 gene deletions in neurofibromatosis type 1.

A set of neurofibromatosis type 1 (NF1) patients was screened for large NF1 gene deletions by comparing patient and parent genotypes at 10 intragenic polymorphic loci. Of 67 patient/parent sets (47 new mutation patients and 20 familial cases), five (7.5%) showed loss of heterozygosity (LOH), indicative of NF1 gene deletion. These five patients did not have severe NF1 manifestations, mental retardation, or dysmorphic features, in contrast to previous reports of large NF1 deletions. All five deletions were de novo and occurred on the maternal chromosome. However, two patients showed partial LOH, consistent with somatic mosaicism for the deletion, suggesting that mosaicism may be more frequent in NF1 than previously recognised (and may have bearing on clinical severity). We suggest that large NF1 deletions (1) are not always associated with unusual clinical features, (2) tend to occur more frequently on maternal alleles, and (3) are an important mechanism for constitutional and somatic mutations in NF1 patients.     

Pain,Perceived Injustice,and Pain Catastrophizing in Chronic Pain Patients in Ireland

Chronic pain is a public health concern affecting 20% to 30% of the population of Western countries. Psychological risk factors can worsen chronic pain patients. Themes of perceived injustice (PI) and pain catastrophizing are related to poor clinical outcomes. Particularly, perceived injustice has not been assessed systematically in patients at their first presentation in chronic pain clinics in Ireland. This study aims to assess the Injustice Experience Questionnaire (IEQ)'s internal consistency in the Irish population, assess PI in patients attending a chronic pain clinic in Ireland using the IEQ, investigate pain catastrophizing through the Pain Catastrophizing Scale (PCS) and its relationship with IEQ scores, and explore their relationships with self‐reported Numeric Pain Rating Scale. One hundred adult patients were randomly selected from those attending the clinic for the first time. Eighty completed the IEQ (mean age 49 years, ranged 22 to 90 years; 59% female). The internal consistency of the IEQ was excellent (Cronbach's alpha = 0.93). Twenty‐six patients (33%) had IEQ scores classified as severe. Patients whose cause of pain was trauma or road traffic accidents were more likely to have clinically severe scores than all other causes of pain (47% vs. 23%, P = 0.03). This has clinical consequences and may have legal implications. Pain catastrophizing scores were strongly correlated with IEQ (r = 0.60, P < 0.001). The correlation between IEQ and the Numeric Pain Rating Scale was weak (r = 0.25, P = 0.048). The results suggest that the IEQ may provide an additional tool to assess psychological contributors in problematic chronic pain patients and to institute targeted therapies to improve clinical outcomes.