Atrial tachycardia masquerading as atrial flutter following ablation of the subeustachian isthmus

We report a case of atrial tachycardia masquerading as atrial flutter in a man who had previously undergone catheter ablation for atrial flutter. The recurrent arrhythmia was electrocardiographically almost identical to the prior atrial flutter; at repeat electrophysiologic study, although bidirectional conduction block was observed in the tricuspid annulus-inferior vena caval isthmus, the atrial arrhythmia was readily initiated. Activation mapping suggested typical atrial flutter, but entrainment techniques demonstrated intra-atrial reentry not involving the ablated isthmus. This case illustrates the need to apply entrainment techniques even in cases of apparent "typical" atrial flutter to confirm that putative ablation targets are necessary for tachycardia perpetuation.     

Utility of Immunologic Testing in Suspected Rheumatologic Disease

The use of diagnostic testing in the clinical practice of medicine has been a shifting landscape from the time that the first blood test was utilized. This is no different in the field of immunology and in particular rheumatology. As the field of immunology is relatively young, the clinical tests are not well established and therefore guidelines for use are still under debate. In this review, we seek to look at some of the key autoantibodies, as well as other tests that are available to diagnose suspected rheumatologic disease, and examine how to best use these tests in the clinic. In particular, we will focus on the anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement, cryoglobulins, rheumatoid factor, and anti-citrullinated protein antibodies.     

Effect of a selection and postoperative care protocol on survival of infants with hypoplastic left heart syndrome

BACKGROUND: We report the development and implementation of a program designed to assign patients preoperatively to either transplant or Norwood procedure based on a score derived from known risk factors and to enhance postoperative care of infants undergoing the Norwood procedure. METHODS: A weighted score for each of six variables comprised the scoring system: ventricular function, tricuspid regurgitation, ascending aortic diameter, atrial septal defect blood flow characteristics, blood type, and age. The scoring system was used to prospectively assign mortality risk and lead to recommendation of either Norwood procedure or transplantation. RESULTS: Survival following the Norwood procedure significantly improved after the management program was implemented (88% versus 40% at 48 hours, 57% versus 10% at 30 days, and 50% versus 10% at 1 year, p < 0.0001 at each time point). The survival of the group that received a score of 7 or less (high risk) who underwent the Norwood procedure was 78% at 48 hours, 44% at 30 days, and 33% at 1 year; survival rates among patients considered lower risk (greater than 7) were 100% at 48 hours and 80% at 30 days and 1 year. Transplant outcomes remained unchanged. CONCLUSIONS: We report improved survival following the Norwood procedure after the implementation of an institutional management approach aimed at improving the outcome of infants with hypoplastic left heart syndrome and may help neutralize historical biases toward Norwood procedure or transplantation.     

Myocardial injury in children following resuscitation after cardiac arrest

BACKGROUND: Myocardial dysfunction occurs immediately after successful cardiac resuscitation. Our purpose was to determine whether measurement of cardiac troponin I in children with acute out-of-hospital cardiac arrest predicts the severity of myocardial injury. METHODS AND RESULTS: This prospective, observational study was performed in the Pediatric Intensive Care Unit (PICU) on 24 patients following arrest, ranging in age from 8 months to 17 years. Troponin measurements were obtained on admission, and at 12, 24, and 48 h. Transthoracic echocardiograms were performed within 24 h after admission. Survival to hospital discharge was 29% (7/24). The mean age was 5.9+/-4.6 years for survivors and 4.2+/-5.3 years for non-survivors. The median (range) duration of cardiac arrest times for survivors was 6 min (3 to 63 min) versus 34 min (4 to 70 min) for nonsurvivors (P=0.02). Survivors received 1.3+/-2.2 doses of epinephrine (adrenaline) compared with 2.9+/-1.6 doses for non-survivors (P=0.02). Only one patient had ventricular fibrillation and defibrillation was unsuccessful. The ejection fraction for survivors averaged 73.2+/-11.2%, but for nonsurvivors only 55.4+/-19.8% (P=0.04). Ejection fraction correlated inversely with troponin at 12 h (r=-0.54, P=0.01) and at 24 h (r=-0.59, P=0.02). Circumferential fiber shortening for survivors was 37.5+/-7.8 and 25.5+/-10.7% for nonsurvivors (P=0.02). It also correlated inversely with troponin (r=-0.46, P=0.03 for survivors and r=-0.65, P=0.01, for nonsurvivors). CONCLUSION: After cardiac arrest and resuscitation in pediatric patients, the severity of myocardial dysfunction was reflected in troponin I levels.     

Presentation, complications, and treatment outcome of brucellosis in Turkish children

Background:  Brucellosis constitutes a public health problem in Turkey. In endemic Brucella melitensis areas such as Turkey, children represent 20–25% of cases.
Methods:  Hospital records of 90 children with brucellosis admitted during a 9 year period, 1997–2006, were evaluated retrospectively.
Results:  Of 90 patients, 27 (30%) were female and 63 (70%) were male ( P  < 0.05). Patients were aged between 1 and 16 years of age. The mean age was 9.02 ± 3.59 years. Fifty-two patients (57.8%) were from rural areas of Turkey. The mode of transmission was consumption of unpasteurized milk and milk products in 64 patients (71.1%). Parents of 41 patients (45.6%) worked in animal breeding. A positive family history for brucellosis was noted in 14 patients (15.6%). The most frequently involved joint with arthralgia was the knee joint. Arthritis was found in six patients (6.7%), and five of the six had monoarthritis. Serum agglutination test was ≥1/160 in 82 patients (91.1%). The joint symptoms rapidly responded to the treatment and the majority of the patients had significant improvement. The duration of treatment was 6 weeks in 81 patients (90%). Six patients experienced relapse. Four patients presented with complications that included neurobrucellosis, discitis and sclerosis of the hip joint.
Conclusions:  Treatment of childhood brucellosis with co-trimoxazole + rifampicin or doxycycline + rifampicin, according to patient age, is effective and has low relapse rates. Complications and relapse were successfully treated with triple-drug regimens with a low sequelae rate.     

Kinetics of the polymerization of styrene with butoxytitanium trichloride and trialkylaluminium

The kinetics of polymerization of styrene in heptane was investigated using butoxytitanium trichloride and triethylaluminium/triisobutylaluminium as cocatalysts. A steady state polymerization after an initial period of declining rates lasting for 20 – 60 min was observed. Both the catalysts systems polymerize styrene at a slow rate ( ≈ 10^?6 mol · dm^?3 · s^?1). The steady state rates show a maximum at an [A1] : [Ti] ratio of 1,5 and exhibit a first-order rate law with reference to both the monomer and the catalyst. Addition of triethylamine, an electron donor, greatly influences the rates of polymerization when triethylaluminium is used, whereas in the case of triisobutylaluminium, the rates are not greatly influenced by the presence or absence of triethylamine. The effect of the electron donor on the rates of polymerization can be explained by the competitive complexation of the alkylaluminium and the electron donor at the active site. The overall activation energy of polymerization (44 – 46 kJ · mol^?1) is in accord with a coordinated anionic mechanism. An alkylated alkoxytitanium halide species as the chemical entity affecting polymerization is suggested.     

Shifting bubble-guided sutureless technique for performing descemetorhexis for retained Descemet’s membrane after penetrating keratoplasty

We describe the use of anterior segment optical coherence tomography in the diagnosis of inadvertent retention of Descemet’s membrane (DM) after penetrating keratoplasty, and a novel technique for its removal in a case of congenital hereditary endothelial dystrophy. In this technique, we use a modification of the shifting bubble technique, commonly used in deep anterior lamellar keratoplasty where a viscocohesive ophthalmic viscosurgical device is injected into the false anterior chamber which causes migration of the central air bubble placed in the anterior chamber peripherally and helps in confirming the correct space. The DM is then peeled in a circular fashion with the help of 23-G vitreoretinal micro forceps.     

Magnetic versus manual guidewire manipulation in neuroradiology: in vitro results

Introduction Standard microguidewires used in interventional neuroradiology have a predefined shape of the tip that cannot be changed while the guidewire is in the vessel. We evaluated a novel magnetic navigation system (MNS) that generates a magnetic field to control the deflection of a microguidewire that can be used to reshape the guidewire tip in vivo without removing the wire from the body, thereby potentially facilitating navigation along tortuous paths or multiple acute curves.Method The MNS consists of two permanent magnets positioned on either side of the fluoroscopy table that create a constant precisely controlled magnetic field in the defined region of interest. This field enables omnidirectional rotation of a 0.014-inch magnetic microguidewire (MG). Speed of navigation, accuracy in a tortuous vessel anatomy and the potential for navigating into in vitro aneurysms were tested by four investigators with differing experience in neurointervention and compared to navigation with a standard, manually controlled microguidewire (SG).Results Navigation using MG was faster (P=0.0056) and more accurate (0.2 mistakes per trial vs. 2.6 mistakes per trial) only in less-experienced investigators. There were no statistically significant differences between the MG and the SG in the hands of experienced investigators. One aneurysm with an acute angulation from the carrier vessel could be navigated only with the MG while the SG failed, even after multiple reshaping manoeuvres.Conclusion Our findings suggest that magnetic navigation seems to be easier, more accurate and faster in the hands of less-experienced investigators. We consider that the features of the MNS may improve the efficacy and safety of challenging neurointerventional procedures.