Idiopathic Ventricular Arrhythmias Detected by an Implantable Loop Recorder in a Child with Exercise-Induced Syncope

Syncope is common in the general population. Despite extensive evaluation, including tilt-table testing and electrophysiologic studies, approximately 30% of cases of recurrent syncope remain unexplained. An implantable loop recorder can be used for diagnosis when recurrent syncope has an idiopathic cause. We present the case of a 9-year-old boy who had a history of recurrent, exercise-induced syncope. Results of physical examination and noninvasive diagnostic testing were inconclusive, and an electrophysiologic study revealed no inducible supraventricular or ventricular arrhythmias. Sixteen months after an implantable loop recorder was placed, the patient had a syncopal episode while swimming in a pool. Cardiopulmonary resuscitation was performed, and data from the loop recorder revealed polymorphic ventricular tachycardia and ventricular fibrillation. A cardioverter-defibrillator was subsequently implanted.Implantable loop recorders can play an important role in the diagnosis of life-threatening arrhythmias in children whose syncope is otherwise unexplained.Key words: Arrhythmias, cardiac/diagnosis; child; electrocardiography, ambulatory/instrumentation/methods; information storage & retrieval/methods; monitoring, physiologic/methods; prostheses and implants; syncope/diagnosis/etiology/therapySyncope, near-syncope, and palpitations are common in children. Although these events are typically benign, they can cause anxiety and concern. Young age and the presence of congenital cardiac problems or ion-channel abnormalities tend to increase the suspicion of severe heart disease. Other factors are syncope''s association with exertion or palpitations, or a family history of sudden cardiac death (SCD).^1–3 Determining the underlying cause is important when evaluating risks and selecting appropriate therapy; however, it can be difficult to pinpoint the cause of syncope in children.⁴ In many cases, physical examination and careful investigation of personal and family medical histories can suffice. The next diagnostic steps involve electrocardiography (ECG), echocardiography, Holter monitoring, stress testing, and sometimes tilt-table testing. Particularly in patients with structural heart disease, arrhythmia can lead to cardiac syncope and necessitate an invasive electrophysiologic (EP) study or catheter ablation.^3,4 Sometimes, however, neither of these can help to determine the mechanism of syncope.An implantable loop recorder (ILR) is a medical device that can monitor heart rhythm for a long time (up to 3 years) and record diagnostic information during syncopal episodes.^4–6 It is implanted in subcutaneous tissue, typically in the pectoral area. The ILR has proved to be effective in monitoring syncope in adults; however, there is less information on its use in children.^6,7 We present the case of a child who had recurrent exercise-induced syncopal episodes, and we describe the role of an ILR in the patient''s diagnosis and treatment.     

Bilateral thoracoscopic sympathectomy for primary hyperhydrosis: a review of 335 cases

Objective

The goal of this retrospective study was to evaluate the outcomes of bilateral video-assisted thoracoscopic sympathectomy for primary hyperhydrosis.

Methods

Between January 2007 and December 2011, a total of 335 patients (192 male, 143 female, mean age 28.3 years) who underwent bilateral thoracoscopic sympathectomy for primary hyperhydrosis were reviewed retrospectively.

Results

Hyperhydrosis occurred in the palmar and axillary region in 175 (52.23%) patients, in only the palmar region in 52 (15.52%), in the craniofacial region in 44 (13.13%), in only the axillary region in 42 (12.53%), and in the palmar and pedal regions in 22 (6.56%) patients. Bilateral thoracoscopic sympathectomy was performed in all patients. The mean follow-up period was 24 (6–48) months. The initial cure rate was 95% and the initial satisfaction rate was 93%. There was no mortality in this study. The complication rate was 15.82% in 53 patients.

Conclusion

Video-assisted thoracoscopic sympathectomy for the treatment of primary hyperhydrosis was effective, with low rates of morbidity and mortality. Despite the appearance of postoperative complications, such as compensatory sweating, patient satisfaction with the procedure was high and their quality of life improved.     

Effect of pediatric advanced life support course on pediatric residents' intubation success

Background: The Pediatric Advanced Life Support Program (PALS) course very important for teaching about intubation, resuscitation, shock, trauma, respiratory failure and rhythm disturbances. The aim of the present study was to evaluate the effect of the PALS course on pediatric residents' intubation success during their rotation, daytime and night‐time practice in the pediatric intensive care unit (PICU). Methods: The study was carried out from 1 March 2005 to 28 February 2007. The study period had two parts, in that the number of attempts and successful intubations performed by pediatric residents, and the pediatric intensivist successful intubation ratio were evaluated in two different periods: before the PALS course, 1 March 2005–28 February 2006, and after the PALS course, 5 March 2006–28 February 2007. The participating residents' pediatric levels (PL) were classed as PL‐1, PL‐2, PL‐3, PL‐4, and all had first experience in the PICU at the PL‐1 level. The PALS instructor was a pediatric emergency or intensive care doctor. We evaluated whether the PALS course influenced intubation success or not. Results: Sixteen residents participated in the study. The proportion of successful intubations was 110 (53.3%) and 104 (65.4%) attempts before and after the PALS course, respectively. The proportion of intubations done by intensivists decreased from 49.1% to 31.7% before and after PALS. The most frequently used endotracheal tube (ETT) internal diameter (ID) was 4.0 mm, and cuffed ETT was used 16% and 21% before and after the course, respectively. Appropriate placing of ETT tip occurred 70.4% and 82.2% of the time before and after the PALS course, respectively. Proportion of successful intubations by residents increased in all levels, except for PL‐1. The most important reason for unsuccessful attempts was inappropriate patient position. Only one patient could not be intubated, and laryngeal mask airway was used in that case. During intubation, complications were broken teeth in two patients before the course, and subglottic stenosis developed in only one patient due to cuffed ETT. Conclusion: Successful intubation is a life‐saving intervention during resuscitation, ETT revision for extubation or obstruction for extubation or obstruction during mechanical ventilation. This skill can be developed in the PALS course and by clinical study in PICU and pediatric emergency services. The PALS course must be given to pediatric residents especially within the first year. Also, cuffed ETT can be used for infants and children.     

Vesiculopustular Eruption in Neonatal Transient Myeloproliferative Disorder

Transient myeloproliferative disorder (TMD) typically presents with pancytopenia, hepatosplenomegaly, and immature circulating white blood cells, and affects approximately 10 % of neonates with Down syndrome. The authors report a neonate with Down syndrome who developed acute widespread pustular eruptions as a sign of TMD. The white blood cell counts on the first day of life were markedly elevated, with blasts seen on examination of the peripheral blood smear. And the patient was noted to have a few erythematous papules and pustules especially on the face. On the following days pathergy positive crusted papules and pustules were increased and spread to trunk and extremities. Skin biopsy specimens showed pustular dermatitis, with subcorneal vesiculopustules and perivascular inflammation in superficial dermis. These lesions improved parallel with the hematologic improvement within two weeks. The authors aim to alert clinicians about this uncommon cause of vesiculopustular eruption with the present illustrative case and review the literature.     

Stanozolol treatment for successful prevention of attacks of severe primary cryofibrinogenemia

Severe essential cryofibrinogenemia is rare in childhood, and both the diagnosis and the management are challenging for pediatricians. An 11‐year‐old male, who had already lost two digits following cold exposure, was referred after multiple visits to various hospitals and subsequently diagnosed as primary cryofibrinogenemia. His history revealed unresponsiveness to calcium channel blockers, acetyl salicylic acid, pentoxifylline, dextran, and steroids. Stanozolol (2 mg/day, orally) prophylaxis was initiated and no new skin lesions developed following starting this treatment. Some of the newly formed lesions at the onset of stanozolol healed. Pediatr Blood Cancer 2010;55:174–176. © 2010 Wiley‐Liss, Inc.     

Evaluation of oxidative stress in children with congenital heart defects

Background: A significant cause of death and chronic illness in childhood is caused by cardiovascular diseases, including congenital heart disease (CHD). This study aims to investigate the oxidative stress status and to establish its association with CHD in children. Methods: The study involves measurements of malondialdehyde (MDA), protein carbonyl (PCO), total anti‐oxidant capacity, high‐sensitive C‐reactive protein (hs‐CRP), fibrinogen and cytokine (interleukin [IL‐6] and tumor necrosis factor‐α) levels in 43 children with CHD and 30 healthy age‐matched children. Results: MDA, PCO, hs‐CRP, fibrinogen, IL‐6 and tumor necrosis factor‐α were significantly elevated while total anti‐oxidant capacity was significantly declined in patients compared with the controls. MDA was positively correlated with PCO, hs‐CRP, Qp/Qs and systolic pulmonary artery pressure. PCO was positively correlated with hs‐CRP, fibrinogen, IL‐6 and systolic pulmonary artery pressure. Conclusion: Oxidative stress and its association with other markers in children with CHD was established. To the best of our knowledge, this is the first time that PCO has been used as a biomarker in CHD and it may be employed as a new diagnostic biomarker in CHD and in the assessment of its severity.     

Prognostic value of expression of p53, proliferating cell nuclear antigen, and c-erbB-2 in laryngeal carcinoma.

BACKGROUND: The molecular mechanisms in malignant transformation of laryngeal mucosa are unknown; many clinical and pathological factors affect prognosis. We investigated a possible correlation between overexpression of p53, proliferating cell nuclear antigen (PCNA), and c-erbB-2, and the clinicopathologic features of laryngeal squamous cell carcinoma (SCC) and clarify their prognostic value. MATERIAL/METHODS: Thirty-three men with laryngeal SCC participated; all underwent primary surgery or surgery plus radiotherapy between 1999 and 2004 at our department. Paraffin sections of laryngeal SCC were immunohistochemically stained for p53, PCNA, and c-erbB-2. RESULTS: Overall, p53 overexpression was found in 16 patients. There was no relation between p53 immunohistochemical staining and tumor region. PCNA immunostaining was significantly stronger in supraglottic tumors compared with glottic tumors. Immunostaining of c-erbB-2 was not different in either location. There was no relation between the T stage of the tumor and p53 and c-erbB-2 immunostaining. However, there was a statistically significant positive correlation between the PCNA staining and T stage (stronger staining was present in T3 and T4 stages than in T1 and T2 stages). CONCLUSIONS: We could not find a statistically significant correlation between p53, PCNA, and c-erbB-2 and lymph node status, histologic differentiation, and survival rate. We demonstrated only a statistically significant positive correlation between PCNA staining and T stage. These data suggest that overexpression of p53, PCNA, and c-erbB-2 is not prognostic in laryngeal SCC.