Postictal generalized EEG suppression is not associated with periictal cardiac autonomic instability in people with convulsive seizures

Purpose: Postictal generalized EEG suppression (PGES) seems to be a pathophysiologic hallmark in ictal recordings of sudden unexpected death in epilepsy (SUDEP). It has recently been suggested that presence and duration of PGES might be a predictor of SUDEP risk. Little is known about the etiology of PGES. Methods: We conducted a retrospective case–control study in 50 people with convulsive seizures (CS) recorded on digital video–electroencephalography (EEG). One CS per individual was reviewed for presence and duration of PGES by two independent observers: Preictal and postictal heart rate (HR) (1 min before seizure onset and 1, 3, 5, 15, and 30 min after seizure end) and frequency domain measures of heart rate variability (HRV), including the ratio of low frequency (LF) versus high frequency (HF) power, were analyzed. The relationship between PGES and periictal autonomic changes was evaluated, as well as its association with several clinical variables. Key Findings: Thirty‐seven individuals (74%) exhibited PGES and 13 (26%) did not. CS resulted in a significant increase of periictal HR and the LF/HF ratio. PGES was associated with neither periictal HR (mean HR difference between PGES+ and PGES? seizures: ?2 beats per minute [bpm], 95% confidence interval [CI] ?10 to +6 bpm) nor HRV change. There was no association between the duration of PGES and periictal HR change. People with PGES were more likely to be asleep before seizure onset (odds ratio [OR] 4.7, 95% CI 1.2–18.3) and had a higher age of onset of epilepsy (median age 15 vs. 4 years). Significance: PGES was not associated with substantial changes in measures of cardiac autonomic instability but was more prevalent in CS arising from sleep.     

Stool Test with Polyclonal Antibodies for Monitoring Helicobacter pylori Eradication in Adults: A Critical Reappraisal

Background: The aims of this work were (a) to evaluate the prevalence of coeliac disease (CD) in a large sample of the Brazilian general population and (b) to compare CD prevalence between children and adults. Methods: The study group comprised 4405 subjects (2629 F and 1776 M). Age distributions were 2034 (1-14 years), 848 (15-29), 584 (30-44), 667 (45-59) and 272 above 60. The immunoglobulin A antiendomysial antibody (IgA-EMA) test was used as the serological screening tool. All sera were submitted to turbidimetric measurement of IgA levels and those with IgA deficiency to the IgG antigliadin (IgG-AGA) test. The small intestinal biopsy was recommended for subjects showing either (a) IgA-EMA positivity or (b) selective IgA deficiency (SigAD) and IgG-AGA positivity. Results: There were 16 EMA positive out of 4405 sera tested. SIgAD was found in five cases (one adult and four children). Two of these children tested positive for IgG-AGA and underwent jejunal biopsy that, in both cases, disclosed a normal mucosa. Overall, 17 out of 18 eligible subjects performed the small intestinal biopsy. The prevalence of biopsy-proven CD in this study group was 3.41 per 1000 individuals. If all 18 EMA-positive patients were included, the overall prevalence would become 3.63 per 1000. The prevalence in adults and children was 2.11 per 1000 and 5.44 per 1000, respectively. Conclusion: This work supports previous findings showing that CD is not a rare disorder in Brazil and that there is an unexplained difference in the prevalence of CD between adults and children.     

Molecular markers of cardiomyopathy in cyanotic pediatric heart disease

Cyanotic congenital heart disease (CHD) accounts for approximately 25% of all types of CHD, encompassing a variety of cardiac anomalies. Children with cyanotic CHD are at risk for heart failure, cardiomyopathy, and arrhythmias. In addition to the hemodynamic burden, recent data suggest that hypoxia may contribute to heart failure. Previous studies have shown that neonatal hypoxia results in significant myocardial gene expression alterations that persist in adulthood after the termination of the hypoxic stimulus in the neonatal period or early infancy. In this article we review the current knowledge on molecular biomarkers of cyanotic CHD pathobiology, and expand on how the current knowledge establishes the basis for future studies to further define the role of molecular tools in cyanotic CHD to improve diagnostic, prognostic and therapeutic strategies.     

Clinical effectiveness of individual patient education in heart surgery patients: A systematic review and meta-analysis

The objective of this systematic review was to compare the effectiveness of individualized patient education interventions to standardized patient education interventions on the rate of readmission, performance of specific health behaviours, depression, anxiety, and cognition during the post-hospital discharge recovery period following cardiovascular surgery.Design and data sourcesRandomized controlled trials that included study participants who underwent their first bypass and/or valve replacement surgery; were eighteen years of age or older; and were recovering in the community.Review methodsFor all data analyzed, data was entered based on the principle of intention to treat. To be included in a given comparison, outcome data had to have been available for at least 80% of those who were randomized. Assessment of statistical heterogeneity was tested. Generic inverse variance methods based on random effects models were used to pool effect estimates across included studies.ResultsSeventeen trials involving 2624 study participants where individualized patient education was the primary interventional intent was included in this review. Four studies that included 930 participants reported on hospital readmissions. The sources of bias that remain unclear or were judged as containing high risk of bias most frequently across included trials were blinding of outcome assessment, incomplete outcome data, and selective reporting. An effect of the individualized patient education in reducing hospital readmission rates (Mean Difference: −1.28, 95% CI −1.87 to −0.68, p < 0.00), depression (Mean Difference: −23.32, 95% CI −23.70 to −22.95, p < 0.00), and anxiety (Mean Difference: −19.34, 95% CI −20.46 to −18.23, p < 0.00) was noted. While an increase in the performance of specific health behaviours (Mean Difference: 3.45, 95% CI 3.27–3.63, p < 0.00) and cognition (Mean Difference: 11.17, 95% CI 10.66–11.68, p < 0.00) was found. Most effect estimates were prone to statistical heterogeneity among the trials.ConclusionThe findings from this systematic review suggest favorable effects on the readmission rates. However, a major limitation notes in the current body of evidence relates to the small number of or even lacking number of trials for clinically important outcomes. As well, the individualized patient education intervention is effective in promoting statistically significant changes in quality of life, performance of health behaviours, depression, and anxiety.     

Use of intravenous morphine for acute decompensated heart failure in patients with and without acute coronary syndromes

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not receive IM, and the adjusted odds ratio (OR) for in-hospital death was: 2.0 (1.1–3.5, P = 0.02). Using propensity analysis, we identified 218 matched pairs of patients who did or did not receive IM. In multivariable analysis accounting for the propensity score (c-statistic 0.82), IM was not associated with increased in-hospital death (OR: 1.2 (0.6–2.4), P = 0.55). Conclusion: IM was used sparingly in our ADHF cohort, and was independently associated with increased in-hospital death in multivariable analysis, but not in propensity score analysis. Thus, IM may be used in ADHF, but with caution. Further randomized trials are warranted.     

Acute Heart Failure after Percutaneous Pulmonary Valve (Melody Valve) Implantation

We present a case of a 38‐year‐old male who developed acute heart failure early after percutaneous pulmonary valve implantation with the Melody valve (Medtronic, Minneapolis, MN, USA).     

Antithrombotic Strategy in the Three First Months following Bioprosthetic Heart Valve Implantation

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)?After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up).Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients.The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.