P2533Prospective randomized study on implanted cardiac rhythm recorders in pregnant women with symptomatic arrhythmia and/or structural heart disease

Background

Cardiac arrhythmia is an important cause of maternal morbidity and mortality in pregnancy, but is difficult to diagnose.

Purpose

The aim of this single-centre, prospective, randomized pilot study was to compare the implantable loop recorder (ILR) with standard assessment of arrhythmia (12-lead ECG; 24-hour Holter ECG) in terms of acceptability, detection of arrhythmias and impact on outcome in pregnant women with symptomatic arrhythmias and/or structural heart disease (SHD).

Methods

The study recruited 40 consecutive patients from a weekly, dedicated cardiac obstetric clinic. Inclusion criteria: symptoms of arrhythmia and/or having SHD at risk of arrhythmia. Patients were randomized to either standard care (SC) or standard care plus ILR (SC-ILR). ILR recordings were read at the monthly visits and/or when presenting with symptoms.

Results

There were no demographic differences between the study groups. Seventeen patients consented to ILR insertion, all of whom found the procedure acceptable. No arrhythmias were recorded by the 12-lead ECGs. Holter monitoring detected arrhythmias in 10 of 23 patients (43%) from the SC group. In the SC-ILR group, 8 of 17 patients (47%) had arrhythmias detected by Holter, whereas 13 of 17 patients (76%) patients had arrhythmias detected by ILR (p=0.157). One of 4 patients with supraventricular tachycardia, 2 of 3 patients with premature ventricular complexes and 2 patients with paroxysmal atrial fibrillation (AF) recorded by ILR did not have the arrhythmias detected by Holter monitoring (Figure 1A shows a scatter plot of the variable R-R intervals seen in AF and 1B a rhythm strip of AF with irregular RR intervals and the absence of P waves, both downloaded from the ILR). Four of these 5 patients (80%) had a change in management as a direct result of their ILR recordings. There were no maternal deaths up to 42 days postpartum in either of the study groups. Nine babies were born with a low birthweight (<2500g), 5 stillbirth/neonatal deaths and 1 pregnancy termination occurred (5 in the Holter group and 1 in ILR group, p=0.37).

Figure 1

Conclusion(s)

This study suggests that an ILR is an acceptable diagnostic modality in pregnant women with a suspected or at risk of arrhythmia. The ILR increased the diagnostic yield to detect arrhythmias that were not detected by routine ECG and Holter monitoring which led to a change in management in the SC-ILR group and was associated with better maternal and neonatal outcomes. The impact of ILR monitoring should be further assessed in larger studies with longer follow up.

Successful Treatment of Recurrent Focal Segmental Glomerulosclerosis After Transplantation in Children: A Single-Center Experience

OBJECTIVE

We aim to report our experience managing cases of recurrent focal segmental glomerulosclerosis (FSGS) in a group of pediatric renal transplant recipients.

METHODS

This study was a retrospective chart review of pediatric patients who had their first kidney transplant at King Faisal Specialist Hospital & Research Center between 2014 and 2016.

RESULTS

We reviewed the files of 6 patients, 3 of whom were male. The median age of the children was 2.75 years (range, 2-4 years) at disease onset, with an average time of progression to end-stage renal disease of 19 months (range, 8-30 months). Five of the patients received a living related donor transplant, and 1 received a living nonrelated donor transplant. Patients had FSGS recurrence at varying intervals (1 to 3 days) post transplant. All cases had plasmapheresis prior to receiving abatacept or rituximab. The therapeutic strategy in 4 patients involved switching tacrolimus to cyclosporine. A complete response was observed in 5 of the 6 patients (83.3%), and treatment was well tolerated in 5 patients. Patient 1 had severe oliguria and required intermittent hemodialysis during the first 3 weeks post transplant. He showed minimal response to the therapeutic plasma exchange and rituximab and was subsequently treated with abatacept. However, he died 8 months post transplant of pneumonia and sepsis.

CONCLUSION

Rituximab and switching tacrolimus to cyclosporine, in conjunction with plasmapheresis, appeared to be effective and safe in children with recurrent FSGS. Conversely, abatacept did not appear to provide clinical benefit.

Suspended low-loss germanium waveguides for the longwave infrared

Germanium is a material of high interest for mid-infrared (MIR) integrated photonics due to its complementary metal-oxide-semiconductor (CMOS) compatibility and its wide transparency window covering the 2-15 μm spectral region exceeding the 4 and 8 μm limit of the silicon-on-insulator platform and Si material, respectively. In this Letter, we report suspended germanium waveguides operating at a wavelength of 7.67 μm with a propagation loss of 2.6±0.3  dB/cm. To the best of our knowledge, this is the first demonstration of low-loss suspended germanium waveguides at such a long wavelength. Suspension of the waveguide is achieved by defining holes alongside the core providing access to the buried oxide layer and the underlying Si layer so that they can be wet etched using hydrofluoric acid and tetramethylammonium hydroxide, respectively. Our MIR waveguides create a new path toward long wavelength sensing in the fingerprint region.

Haemorrhage and other complications in pregnant women on anticoagulation for mechanical heart valves: a prospective observational cohort study

OBJECTIVE

To document maternal and foetal morbidity and mortality in anticoagulated, pregnant patients with mechanical heart valves until 42 days postpartum.

METHODS

In a tertiary single-centre, prospective cohort, 178 consecutive patients at the cardiac-obstetric clinic were screened for warfarin use between 1 July 2010 and 31 December 2015. Of 33 pregnancies identified, 29 were included. Patients received intravenous unfractionated heparin from six to 12 weeks' gestation and peripartum, and warfarin from 12 to 36 weeks. Maternal outcomes including death, major haemorrhage and thrombosis, and foetal outcomes were documented.

RESULTS

There were two maternal deaths, five returns to theatre post-delivery, eight patients transfused, six major haemorrhages, one case of infective endocarditis and three ischaemic strokes. Ten pregnancies had poor foetal outcomes (six miscarriages, three terminations, one early neonatal death). Twenty patients required more than 30 days' hospitalisation, and 15 required three or more admissions. HIV positivity was associated with surgical delivery (p = 0.0017).

CONCLUSION

Complication rates were high despite centralised care.

Effects of a pH 7.4, lactate-based and a pH 7.4, bicarbonate-based peritoneal dialysis solutions on neutrophil superoxide generation

Neutrophil superoxide formation was similar when cells were incubated in self-made, non-autoclaved, pH 7.4, lactate-based peritoneal dialysis solutions or in their self-made, non-autoclaved, pH 7.4, bicarbonate-based counterparts. On the other hand, commercially available, autoclaved, pH 7.4, lactate-based peritoneal dialysis solutions resulted in inhibition of superoxide production when compared to their self-made, non-autoclaved, pH 7.4, lactate-based or bicarbonate-based counterparts. The cause for this inhibition of superoxide generation is at present unknown.

Suspended silicon waveguides for long-wave infrared wavelengths

In this Letter, we report suspended silicon waveguides operating at a wavelength of 7.67 μm with a propagation loss of 3.1±0.3  dB/cm. To our knowledge, this is the first demonstration of low-loss silicon waveguides at such a long wavelength, with loss comparable to other platforms that use more exotic materials. The suspended Si waveguide core is supported by a sub-wavelength grating that provides lateral optical confinement while also allowing access to the buried oxide layer so that it can be wet etched using hydrofluoric acid. We also demonstrate low-loss waveguide bends and s-bends.

Effect of the 2008 economic crisis on the cardiovascular mortality of the Irish population: an ecological 12-year study of a heart-broken Celtic Tiger

Ireland has endured a substantial financial crisis in 2008 and we sought to explore the effect of economic recession on Irish cardiovascular mortality. We found an increase by 17.2% in CVA-deaths during the financial crisis years (95% CI 11.1% to 23.6%). In males, we found a notable rise in the annual IHD rate by 7.56% (95% CI 4.73% to 10.46%), in annual MI rate by 2.96% (95% CI 0.16% to 5.84%), and in annual CVA death rate by 20.07% (95% CI 16.13% to 24.14%). In females our findings indicated an increased rate of CVA-related deaths during the economic crisis by 15.54% (95% CI 6.67% to 25.16%). Irish CVA-related deaths increased during the economic crisis for males and females alike. Male IHD-related deaths have also risen indicating a potential differential effect for financial hardships on male gender mortality.

The effect of intrauterine HCG injection on IVF outcome: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of intrauterine HCG infusion before embryo transfer on IVF outcomes (live birth rate, clinical pregnancy rate and spontaneous aboretion rate) was investigated. Searches were conducted on MEDLINE, EMBASE and The Cochrane Library. Randomized studies in women undergoing IVF and intracytoplasmic sperm injection comparing intrauterine HCG administration at embryo transfer compared with no intrauterine HCG were eligible for inclusion. Eight randomized controlled trials were eligible for inclusion in the meta-analysis. A total of 3087 women undergoing IVF and intracytoplasmic sperm injection cycles were enrolled (intrauterine HCG group: n = 1614; control group: n = 1473). No significant difference was found in the live birth rate (RR 1.13; 95% CI 0.84 to 1.53) and spontaneous abortion rate (RR 1.00, 95% CI 0.74 to 1.34) between women who received intrauterine HCG and those who did not receive HCG. Although this review was extensive and included randomized controlled trials, no significant heterogeneity was found, and the overall included numbers are relatively small. In conclusion the current evidence does not support the use of intrauterine HCG administration before embryo transfer. Well-designed multicentre trials are needed to provide robust evidence.

MRI of inflammatory spondyloarthropathy following traumatic cauda equina syndrome

BACKGROUND CONTEXT

Spondyloarthropathy has been described radiographically in patients following paralysis from spinal cord trauma. Onset of these findings after cauda equina syndrome have not been reported previously. Furthermore, the magnetic resonance documentation of its early evolution has not been recorded.

PURPOSE

We report a case of early-onset spondyloarthropathy shown by magnetic resonance imaging (MRI) in a patient with cauda equina syndrome due to bilateral sacral insufficiency fractures.

STUDY DESIGN

Unique case study review, one case.

METHODS

Review of the clinical case notes and imaging including initial and subsequent MR imaging.

RESULTS

The initial MRI of the lumbosacral spine showed bilateral sacral insufficiency fractures with a kyphotic deformity. The vertebral bodies were normal on the initial computed tomography and MRI studies, which did not reveal pre-existing features of sacroiliitis. The second MRI performed 5 months later clearly showed spondylitis at multiple vertebral levels with partial resolution 18 months post injury.

CONCLUSION

Spondyloarthropathy in patients with paralysis due to spinal cord injury is well documented in the English language literature, but until now this has not been demonstrated by MRI. It is a rare complication of traumatic cauda equina syndrome that commences soon after the traumatic event and can resolve spontaneously.