Use of the Wearable External Cardiac Defibrillator in Children

Background: The wearable cardiac defibrillator (WCD) is an alternative to the implantation of cardioverter defibrillator (ICD) for patients at risk for sudden death who do not fulfill standard criteria for ICD implantation or in whom the risk:benefit ratio is equivocal. Published data pertaining to the WCD in children is sparse. We describe the utility of the WCD in children at a single tertiary care center. Methods: We retrospectively identified all patients aged birth to 18 years of age who were prescribed a WCD between January 1, 2007, and June 30, 2009. Patient information regarding diagnosis, clinical history, electrocardiograms, rhythm reports, and outcome at last follow‐up was reviewed. Information regarding the WCD was obtained including indication for use, patient compliance, and accuracy of rhythm determination, inappropriate and appropriate shock events, and other complications. Results: Since 2007, four patients age less than or equal to 18 years have been prescribed the WCD at our institution. None of the patients had an inappropriate shock. Two patients had documented noncompliance with wear, which resulted in failure to detect and treat a life‐threatening arrhythmia in one. Two patients required downsizing of the WCD during use in order to improve electrode contact and rhythm detection. Conclusions: The WCD is an option for children of appropriate size who are at increased risk for sudden cardiac death, but in whom the risk of ICD implantation outweighs the benefit. Careful patient selection and education is important to ensure safety, as noncompliance with wear was common in this series of children. (PACE 2010; 33:742–746)     

Insufflation vs intubation during esophagogastroduodenoscopy in children

Objectives: We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation. Background: Optimum airway management during EGD in children remains undecided. Methods/materials: Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi‐square contingency tables or Fisher’s exact test as appropriate. Results: Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD. Conclusions: Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.     

Outbreak of Rash in Children Associated with Recreational Mud Exposure

Abstract: We conducted an investigation of a rash outbreak in children who attended the “Mud Mania Festival.” The mean incubation period of illness was 26 hours, and mean duration was 4.3 days. Time spent in mud was associated with the extent of rash in a dose–response fashion. The cultures from lesions of two unrelated cases yielded Enterobacter cloacae.     

Intrastriatal grafts of rat colonic smooth muscle lacking myenteric ganglia stimulate axonal sprouting and regeneration

Grafts of living or freeze-killed freshly dissected colonic smooth muscle from young inbred Fischer rats were implanted into the corpus striatum of adult Fischer rats. Sections of brain were examined electron microscopically 3 and 6 wk after implantation. At both times, living grafts were vascularised and contained healthy differentiated smooth muscle cells, fibroblasts, interstitial cells of Cajal and some macrophages. Large bundles of small nonmyelinated axons, identified as CNS axonal sprouts, could be observed in the brain at and near the interface between the living smooth muscle and the CNS tissue. Bundles of regenerating CNS axons, often associated with astrocyte processes, had grown into the grafts. Some axons within the grafts had matured, enlarged and become myelinated by oligodendrocyte processes or Schwann cells. In some cases, smooth muscle cells were observed in close and intricate association with axons. In contrast to the living grafts, grafts of freeze-killed smooth muscle, examined 3 and 6 wk after implantation, contained macrophages, fibroblasts, collagen and large amounts of cellular debris, but no living muscle cells, astrocytes or Schwann cells. The striatal neuropil around freeze-killed grafts did not contain large bundles of CNS axonal sprouts and bundles of axons were not observed within the freeze-killed graft. This study demonstrates that cells from the smooth muscle layers of the colon, in the absence of myenteric ganglia, can stimulate a vigorous regenerative response from CNS axons when implanted into the corpus striatum of adult rats.     

The role of social support and stressors for mothers and infants

This correlational study of mothers and their 6-month-old infants examined the importance of social support and stressors for parenting and infant development. Mothers (n = 79) were primarily White, married, and ranged in socio-economic status from low to high. All data were collected in mothers' homes when infants were 6 months old. Diversity of sources of social support and diversity of father support were positively related to parenting (quality of stimulation in the home). Diversity of sources of social support buffered the negative relationship of maternal fatigue (stressor) to parenting. Parenting was related to social, hearing-speech, locomotor, and general development. Additionally, social support and aggravation (people in the mother's said network who make life difficult) were related to infant development, independent of parenting.     

NORMAL CIRCULATING IMMUNOREACTIVE GROWTH HORMONE RELEASING FACTOR (hGRF) CONCENTRATIONS IN PATIENTS WITH FUNCTIONAL HYPOTHALAMIC hGRF DEFICIENCY

Using a highly specific radioimmunoassay we have measured the concentrations of human growth hormone releasing factor (ir-hGRF) in the peripheral circulation of six individuals with acquired hypothalamic hGRF deficiency. Despite their hypothalamic dysfunction venous plasma ir-hGRF increased normally in every patient after the stimulus of a mixed breakfast, from an average concentration basally of 13.6 +/- 6.0 pg/ml to a maximum of 29.0 +/- 8.4 pg/ml (mean +/- SEM) at 120 min. The findings indicate that circulating hGRF is at least in large part extrahypothalamic in origin, which in turn implies a physiological role for hGRF in the periphery.     

Creating supportive environments for health: a case study from Australia in developing national goals and targets for healthy environments

Creating healthy living and working conditions are central goalsin public health which have re-emerged in prominence in thepast decade. The roots of thLs revival of interest can be tracedto include improved under standing of the relationship betweenliving conditions and health, prompting by the World HealthOrganiza non (WHO) through its ‘Health for All’strategy which has drawn attention to underlying causes of inequitiesin health in society, and a more general international concernwith ecologically sustainable development. Australia has respondeduniquely to the challenge of developing a strategy to createsustainable, supportive environments for health through itsNational Health Goals and Targets. These targets, publishedin 1993, include a range of targets for Healthy Environmentswhich were developed from a ‘health’ perspective,but in co-operation with the different sectors of governmentresponsible for action to achieve them. These include housing,transportation, education and employment. Early responses tothe publication of the targets are encouraging, but will requiresustained governmental support to reach fruition. Critical tosuccess in develop ing and implementing the targets will berecognition by government, and particularly the health sector,of the legitimacy of inter-sectoral action for health. Negotiations to resolve potential conflicts in the priorities of differentsectors should ensure that attention is focused on the commonground for practical inter-sectoral action to improve health.The Australian Targets Report identifies a series of concreteactions required to create supportive environments for health.A willingness to account for pro gress in achieving the targetsfor Healthy Environments will be an important measure of thecom mitment of the Australian federal and state governmentsto the health and well-being of their citizens.     

Efficacy of Type 1C Antiarrhythmic Agents for Treatment of Resistant Atrial Fibrillation

In order to determine the efficacy of type lC agents (flecainide, encainide, propafenone) in patients with atrial fibrillation who have failed to maintain sinus rhythm with type 1A agents (quinidine, procainamide, disopyramide), 147 patients, that were admitted into the John Dempsey Hospital with new or recurrent atrial fibrillation between 1987–1991, were studied retrospectively. Out of the total, 29 patients converted spontaneously to sinus rhythm, 14 patients were left in atrial fibrillation, and 104 patients were given a type 1A antiarrhythmic. Sixty-five of these patients remained in sinus rhythm (54% converted on drug alone, 46% required electrical cardioversion) for at least 6 months. Of the remaining 39 patients, 28 were given a type 1C antiarrhythmic; 13 were successfully converted (61% chemical, 39% electrical) to and remained in sinus rhythm for at least 6 months; the remaining 15 either failed to convert or reverted to atrial fibrillation. New onset atrial fibrillation had a significantly lower incidence of congestive heart failure (10%) than recurrent atrial fibrillation (33%; P < 0.01). No differences in digoxin, beta blocker use, or other clinical characteristics were seen either between type 1A or type 1C successes or failures. Similarly, echocardiographic dimensions did not predict success or failure with either class of agent. In conclusion, type lC antiarrhythmics for suppression of recurrent atrial fibrillation represent a reasonable therapeutic alternative for suppression of atrial fibrillation in patients who have failed type lA agents. Prognostic factors predicting success or failure remain undetermined.