Polymorphic Ventricular Tachycardia Storm After Coronary Artery Bypass Graft Surgery: A Form of 'Angry Purkinje Syndrome'

BACKGROUND

Polymorphic ventricular tachycardia (PMVT) is a highly lethal arrhythmia which is commonly caused by acute myocardial ischaemia. PMVT mediated by short-coupled ventricular ectopy patients with ischaemic heart disease but in the absence of acute ischaemia may relate to transient peri-infarct Purkinje fibre irritability and has been termed 'Angry Purkinje Syndrome'.

METHODS

We present a case series of three patients with PMVT storm 3-5 days following coronary artery bypass graft surgery (CABG). In all three cases, recurrent episodes of PMVT were initiated by monomorphic ventricular ectopy with a short coupling interval. Acute coronary ischaemia was excluded in all three patients with a coronary angiogram and graft study. Two out of three of the patients commenced oral quinidine sulphate with subsequent rapid suppression of arrhythmia. Implantable cardiac defibrillators were implanted in all three patients and revealed no recurrence of PMVT following hospital discharge.

CONCLUSION

The Angry Purkinje Syndrome is a rare but important cause of ventricular tachycardia storm after CABG surgery and is mediated by short-coupled ventricular ectopy in the absence of acute myocardial ischaemia. This arrhythmia may be highly responsive to quinidine.

Return to Sport and Performance After Thumb Metacarpophalangeal Joint Collateral Ligament Surgery in the National Basketball Association

Introduction Basketball players are at increased risk of thumb collateral ligament injury (ulnar collateral ligament (UCL) and radial collateral ligament (RCL)). Methods The National Basketball Association (NBA) players with thumb collateral ligament surgery were identified using publicly available data. Performance statistics, ligament injuries (UCL or RCL), return to sport (RTS) time, laterality, and injury dates were recorded. Cases were matched 1:1 with controls based on age (±1 year), body mass index (BMI), NBA experience (±1 year), and performance statistics prior to the index date. RTS was defined as playing in one NBA game postoperatively. Career longevity was evaluated. Summary statistics were calculated, and Student's t-tests (ɑ = 0.001) were performed. Results All 47 players identified with thumb collateral ligament surgeries returned to sport. Thirty-three players (age: 26.9 ± 3.0) had one year of postoperative NBA experience for performance analysis. Career length (case: 9.6 ± 4.1, control: 9.4 ± 4.3, p > 0.001) was not significantly different from controls (p > 0.001). The same season time to RTS (n = 20) was 7.1 ± 2.4 weeks. Off-season or season-ending surgery (n = 13) RTS time was 28.4 ± 18.7 weeks. Neither thumb collateral ligament (UCL, n = 7; RCL, n = 10; unknown, n = 16) had an identifiable difference between the groups when evaluating career length. Career length, games/season, and performance were not different for players who underwent surgery on their dominant thumb (63.6%, 21/33) compared to controls (p > 0.001). Conclusion RTS rate is high in NBA athletes undergoing thumb collateral ligament surgery. Players do not experience decreased performance or career length due to thumb collateral ligament surgery, regardless of a dominant or non-dominant thumb injury.

Non-ischaemic dilated cardiomyopathy: recognising the genetic links

The landscape of genetically related cardiac disease continues to evolve. Heritable genetic variants can be a primary cause of familial or sporadic dilated cardiomyopathy (DCM). There is also increasing recognition that genetic variation is an important determinant of susceptibility to acquired causes of DCM. Genetic forms of DCM can show a wide variety of phenotypic manifestations. Identifying patients who are most likely to benefit from genetic testing is paramount. The objective of this review is to highlight the importance of recognising genetic DCM, key genotype-phenotype correlations and the value of genetic testing in clinical management for both the individual and their family. This is likely to become more relevant as management strategies continue to be refined with genotype-specific recommendations and disease-modifying therapies.

Giant Diffusion of Nanomechanical Rotors in a Tilted Washboard Potential

We present an experimental realization of a biased optical periodic potential in the low friction limit. The noise-induced bistability between locked (torsional) and running (spinning) states in the rotational motion of a nanodumbbell is driven by an elliptically polarized light beam tilting the angular potential. By varying the gas pressure around the point of maximum intermittency, the rotational effective diffusion coefficient increases by more than 3 orders of magnitude over free-space diffusion. These experimental results are in agreement with a simple two-state model that is derived from the Langevin equation through using timescale separation. Our work provides a new experimental platform to study the weak thermal noise limit for diffusion in this system.

Arrhythmic Phenotypes Are a Defining Feature of Dilated Cardiomyopathy-Associated SCN5A Variants: A Systematic Review

BACKGROUND

Variants in the SCN5A gene, that encodes the cardiac sodium channel, Nav1.5, are associated with a highly arrhythmogenic form of dilated cardiomyopathy (DCM). Our aim was to review the phenotypes, natural history, functional effects, and treatment outcomes of DCM-associated rare SCN5A variants.

METHODS

A systematic review of reported DCM-associated rare SCN5A variants was undertaken using PubMed and Embase.

RESULTS

Eighteen SCN5A rare variants in 29 families with DCM (173 affected individuals) were identified. Eleven variants had undergone experimental evaluation, with 7 of these resulting in increased sustained current flow during the action potential (eg, increased window current) and at resting membrane potentials (eg, creation of a new gating pore current). These variants were located in transmembrane voltage-sensing domains and had a consistent phenotype characterized by frequent multifocal narrow and broad complex ventricular premature beats (VPB; 72% of affected relatives), ventricular arrhythmias (33%), atrial arrhythmias (32%), sudden cardiac death (13%), and DCM (56%). This VPB-predominant phenotype was not seen with 1 variant that increased late sodium current, or with variants that reduced peak current density or had mixed effects. In the latter groups, affected individuals mainly showed sinus node dysfunction, conduction defects, and atrial arrhythmias, with infrequent VPB and ventricular arrhythmias. DCM did not occur in the absence of arrhythmias for any variant. Twelve studies (23 total patients) reported treatment success in the VPB-predominant cardiomyopathy using sodium channel-blocking drug therapy.

CONCLUSIONS

SCN5A variants can present with a diverse spectrum of primary arrhythmic features. A majority of DCM-associated variants cause a multifocal VPB-predominant cardiomyopathy that is reversible with sodium channel blocking drug therapy. Early recognition of the distinctive phenotype and prompt genetic testing to identify variant carriers are needed. Our findings have implications for interpretation and management of SCN5A variants found in DCM patients with and without arrhythmias.

[If you were to have another abortion, would you choose the same method? A study on 1032 patients' level of satisfaction]

INTRODUCTION

In 2016, the French National College of Gynaecologists and Obstetricians revised the recommandations on abortion care. Abortions can now be medical, regardless of the term, depending on the patients' preference. The aim was to assess the influence of the term and method on patients' satisfaction, in Haute-Normandie.

METHOD

This is a prospective multicentric study. A questionnaire was completed by patients the day of the hospitalization. The main efficacy parameter was the patient's satisfaction depending on term and method.

RESULTS

A total of 1032 patients were included from November 2018 till August 2019: 733 medical abortions and 259 surgical abortions. For equivalent terms, medical abortion was associated with a lower satisfaction, OR: 1.9, CI 95 % [1.23; 2.99] P=0.004. For equivalent methods, a term higher than 9 weeks of gestation was also associated with a lower satisfaction OR: 1.56, CI 95 %: [1.09; 2.23], P=0.01. The satisfaction rate was up to 4 out of 5, regardless of the term or the method. For equivalent term and method, an imposed method due to the term was associated with a lower satisfaction OR:3.82, CI 95 % [2.15;6.90], P<0.001.

CONCLUSION

Term higher than 9 weeks of gestation, medical abortion and an imposed method are associated with a lower satisfaction.

Incidence of Premature Lead Failure in 2088 TendrilTM Pacing Leads: A Single Centre Experience

BACKGROUND

Recent reports describe a high rate of premature lead failure in the St Jude/Abbott Tendril^TM 2088 (St. Jude Medical Inc., St. Paul, MN, USA) pacing lead principally manifested by electrical noise. This finding awaits confirmation.

METHODS

We performed a retrospective analysis of 2088 Tendril^TM leads among 362 patients implanted from 2010 to 2018. Eligible leads were those with device interrogations beyond one month from lead implantation. Review of serial device interrogations was conducted for each lead, particularly focussing on electrical noise as a marker of premature lead dysfunction.

RESULTS

Four hundred and eight (408) leads among 337 patients were included in this study, with an average patient age of 81±11 years at the time of lead implantation. Mean follow-up was 2.5±1.8 years. There were eight leads with electrical noise indicating premature lead failure. This reflects an overall 1.7% rate of lead dysfunction; the failure rate was 6.2% at 4 years. The majority of cases were detected during routine checks without adverse clinical consequences. Four (4) cases required device reprogramming to avoid interference or inhibition due to noise.

CONCLUSION

The rate of Tendril ^TM 2088 premature lead failure appears to be similar to recent local and international studies. This study reports a significantly higher rate of lead dysfunction at 4 years (6.2%) than the published Abbott product performance reports.

PARP inhibitor-induced torsades de pointes in long QT syndrome: a case report

Background

Poly ADP-ribose polymerase (PARP) inhibitors target pathogenic BRCA mutations in chemotherapy-resistant malignancies. PARP inhibitors cause modest dose-dependent QT prolongation in the setting of a normal baseline QT interval.

Case summary

We describe a case of PARP inhibitor-induced torsades de pointes (TdP) in an 86-year-old gentleman prescribed rucaparib due to chemotherapy-resistant, metastatic prostate cancer with pre-existing long QT, with an apparent dose-dependent increase in QT interval. The patient presented with syncope and recurrent TdP requiring direct cardioversion reversion (200 J biphasic) and an isoprenaline infusion (2 μg/min). There were no other QT prolonging agents and no electrolyte or metabolic disturbance to account for this arrhythmia. Improvement in QT interval was observed within 72 h of rucaparib cessation.

Discussion

PARP inhibitors cause a modest, dose-dependent increase in QT interval in patients with a normal baseline. The safety of PARP inhibitors in patients with pre-existing long QT has not been evaluated. This is the first reported case of rucaparib-associated TdP in a patient with pre-existing long QT, highlighting the amplified effect of this agent in individuals with pre-existing QT prolongation and the risk of fatal arrhythmias.

Long-term implant of intramuscular sensors and nerve transfers for wireless control of robotic arms in above-elbow amputees

Targeted muscle reinnervation (TMR) amplifies the electrical activity of nerves at the stump of amputees by redirecting them in remnant muscles above the amputation. The electrical activity of the reinnervated muscles can be used to extract natural control signals. Nonetheless, current control systems, mainly based on noninvasive muscle recordings, fail to provide accurate and reliable control over time. This is one of the major reasons for prosthetic abandonment. This prospective interventional study includes three unilateral above-elbow amputees and reports the long-term (2.5 years) implant of wireless myoelectric sensors in the reinnervation sites after TMR and their use for control of robotic arms in daily life. It therefore demonstrates the clinical viability of chronically implanted myoelectric interfaces that amplify nerve activity through TMR. The patients showed substantial functional improvements using the implanted system compared with control based on surface electrodes. The combination of TMR and chronically implanted sensors may drastically improve robotic limb replacement in above-elbow amputees.

Revision der CEAP-Klassifizierung für chronische Venenleiden

Die CEAP-Klassifizierung für chronische Venenleiden wurde 1994 durch ein internationales Ad-hoc-Komitee des American Venous Forum entwickelt, durch die Society for Vascular Surgery unterstützt und 1995 in die „Reporting Standards in Venous Disease“ inkorporiert. Inzwischen benutzen die meisten publizierten klinischen Arbeiten das CEAPSystem, ganz oder in Teilen.

Um die Klassifizierung nicht als statisches System zu belassen, hat ein Ad-hoc-Komitee des American Venous Forum in Zusammenarbeit mit einem internationalen Verbindungskomitee eine Reihe von praktischen Änderungen empfohlen, die in diesem Konsensusbericht aufgelistet sind. Diese beinhalten eine Verfeinerung verschiedener Definitionen, welche der Beschreibung von chronischen Venenerkrankungen dienen, eine Verfeinerung der C-Klassen von CEAP, der Zusatz der Beschreibung n (no venous abnormality), das Datum der Klassifizierung, die Untersuchungsstufe sowie, als einfachere Alternative zur vollen (fortgeschrittenen) CEAP-Klassifizierung, die Einführung einer Basis-CEAP-Version. Es ist wichtig, darauf hinzuweisen, dass CEAP eine deskriptive Klassifizierung darstellt, wogegen das „Venous severity scoring“ sowie Lebensqualitäts- Scores Instrumente für longitudinale Outcome-Studien darstellen.

Sonographic screening for developmental dysplasia of the hip in preterm breech infants: do current guidelines address the specific needs of premature infants?

OBJECTIVE

To assess the association between gestational age versus corrected age at the time of hip ultrasound with findings for developmental dysplasia of the hip (DDH) in preterm breech infants.

STUDY DESIGN

A retrospective medical chart review was conducted to examine hip ultrasounds of 318 premature breech infants for findings associated with DDH.

RESULTS

Positive findings for DDH occurred in 3/135 (2%) of infants <32 weeks gestational age and 17/183 (9%) of infants 32 to <37 weeks gestational age (odds ratio: 0.22, 95% CI: 0.04 to 0.79, P<0.015). No infants born <32 weeks gestational age had abnormal findings for DDH upon follow-up ultrasound. Infants <40 weeks corrected age at the time of hip ultrasound were more likely to have DDH findings compared with infants ⩾44 weeks corrected age (odds ratio: 7.83, 95% CI: 2.20 to 29.65, P<0.001).

CONCLUSION

Current hip ultrasonography policies that include screening of premature breech infants may need to be revised.

Anatomical Patterns in Varicose Vein Disease: A Duplex Scanning Study

Objectives:

To determine symptomatology, clinical class, and topographic patterns of varicose veins in a consecutive series of patients with venous complaints.

Methods:

We performed clinical examination and duplex scanning of 498 lower limbs in 317 patients with obvious varicose veins for whom no previous treatment had been undertaken.

Results:

Classes of chronic venous insufficiency (CVI) in 498 legs: grade 0: 117 (23.5%); gr 1: 310 (62.2%); gr 2: 47 (9.4%); gr 3: 24 (4.8%). Duplex-detected venous reflux was found in the greater saphenous vein territory (junction or trunk or related perforator or main tributary) in 423 limbs (85.3%) the sapheno-femoral junction was incompetent in only 342 legs (68.7%). Reflux was found in the lesser saphenous vein territory in 100 limbs (20.1%) and in sapheno-popliteal junction in 92 (18.5%). Strictly non saphenous origin of varicosities was found in 31 limbs (6.2%). Deep venous incompetence was found in 48 legs (9.6%).

Conclusions:

These findings yield data on the distribution and occurence of lower limbs venous lesions in patients with varicose disease.

Surgical Options in Post-Thrombotic Syndrome

Objective:

To review the outcome of surgical restoration of deep vein competence in 53 patients with post-thrombotic syndrome.

Design:

Single patient group.

Setting:

Unite de Pathologie Vasculaire Jean Kunlin, Clinique du Grand-Large, av. Leon-Blum, Decines Charpieu, France.

Patients:

Fifty-three patients with clinical and radiological evidence of post-thrombotic syndrome uncontrolled by conventional conservative treatment.

Interventions:

Surgical restoration of deep vein competence by one of four methods: valvuloplasty, vein transplantation, vein transposition, or Psathakis' sling procedure.

Main outcome measures:

Sustained ulcer healing, photoplethysmography (PPG) refilling times, abolition of venous reflux on duplex scanning, symptomatic improvement.

Results:

All four techniques led to sustained ulcer healing in approximately two-thirds of patients. There was a poor correlation between maintenance of ulcer healing and improvement in PPG refilling times or abolition of reflux on duplex ultrasound.

Endoluminal treatment of lower limb varicose veins by endovenous laser and radiofrequency techniques

Objective: New endovenous treatment techniques for varicose veins – endovenous laser (EVLT) and radiofrequency (RF) – have been the subject of numerous publications during recent years. The aim of this study was to analyse the articles published in English and French and to compare the two procedures with classical surgery.

Methods: While RF uses only one type of device, manufactured and distributed by a sole company, EVLT uses different types of lasers, manufactured and marketed by several companies. Therefore, RF benefits from a unique and well-defined protocol of practice, in contrast with EVLT which presents multiple variants.

Results: The short-term postoperative clinical status was studied in two controlled randomized trials comparing RF therapy with classical surgery, including one study that used a quality of life questionnaire. The results, including return to normal activity and convalescence duration assessment, were more favourable after RF therapy. In terms of thromboembolic complications investigated by systematic ultrasound duplex examination, the two procedures presented an approximately equal success rate of 0.5%. Other postoperative complications were transient: RF was associated with sensory nerve complications like paresthesia, while pain was more pronounced after EVLT. Results were difficult to analyse in terms of varicose vein treatment. In terms of signs and symptoms, detailed results were available at the three-year follow up for RF therapy. The improvement was very significant compared with the preoperative status and roughly equivalent to that previously reported for classical surgery. Clinical results after EVLT are less documented. Haemodynamic results by duplex ultrasound examination are well documented for RF but less detailed for EVLT. In a single-centre study, vein obliteration after EVLT was 93.4% at the two-year follow up and 88% after RF in a multicentre study at the three-year follow up. Correlation between clinical and haemodynamic results was established for RF at the two-year follow up and showed a strong link between the clinical results and absence of reflux. Finally, cost estimation of the two techniques showed that the EVLT fibre is cheaper than the RF catheter, the situation being inverse for the generators. The global cost of the RF procedure (including convalescence) was compared with classical surgery in a study. The findings favour RF for active patients.

Conclusions: In the absence of long-term controlled results comparing classical surgery and sclerotherapy with endoluminal surgery, the latter method was proved to be less aggressive postoperatively and effective at mid-term.

Dynamic Popliteal Phlebography

Phlebography of the popliteal vein is reviewed. An anatomical summary considers the superficial and deep venous systems, perforating veins and the gastrocnemius veins. Techniques and methods are described. Results of 2500 investigations are reported To date the puncture failure rate is only 0.3%. The method is useful in identifying incompetence in a wide variety of veins, varicose veins and post-phlebitic disease. The system is compared to other types of investigation. It is concluded that the technique enables a rapid evaluation of venous pathology in many instances and is ideal for use on out-patients.

Investigation of Popliteal Fossa Venous Reflux

Objective:

To assess the relative diagnostic merits of duplex scanning (DS) and dynamic popliteal phlebography (DPP) in the investigation of popliteal fossa venous reflux.

Design:

Prospective single patient study.

Setting:

Departments of Vascular Surgery, Radiology and Angiology, Jean Kunlin Unit of Vascular Pathology, Clinique du Grand-Large, Declines Charpieu, France.

Patients:

Eighteen consecutive patients with venous reflux in the popliteal fossa as demonstrated by hand-held Doppler insonation.

Interventions:

All limbs were investigated by DS and DPP before undergoing surgical exploration of the Popliteal fossa.

Main outcome measures:

The findings of the two modes of investigation were compared with the operative findings.

Results:

Both tests showed good specificity (98% DPP, 96% DS), but only moderate sensitivity (83% DPP, 87.5% DS). Both tests were wrong in two limbs.

Conclusion:

Phlebography can be reserved for cases where duplex scanning is inconclusive. Unsuspected anomalies will occasionally be found at operation despite exhaustive investigation.

Primary Venous Aneurysms of the Popliteal Fossa

Objective:

To report five cases of primary venous aneurysm arising in the popliteal fossa.

Setting:

Unite de Pathologie Vasculaire Jean Kunlin, Clinique du Grand-Large, av. Leon-Blum, Decines Charpieu, France.

Patients:

Five patients with radiological evidence of venous aneurysm in the popliteal fossa.

Interventions:

Surgical repair in all cases.

Main outcome measures:

Avoidance of pulmonary embolism.

Results:

Satisfactory postoperative recovery in all. No complications or subsequent pulmonary emboli.

Diurnal temperature cycle deduced from extreme daily temperatures and impact over a surface reanalysis system

Abstract. Due to the evolution of the observation network, hourly 2 m temperature analysis performed by reanalysis systems shows temporal inhomogeneities. The observation network gap is less present for extreme daily temperature observations. In order to reduce inhomogeneities and enable a climatological use of temperature analysis, information from extreme temperatures could be useful. In this study, the diurnal temperature cycle has been reconstructed for stations which only record extreme temperatures. These new "pseudo" hourly temperature observations are then provided to the analysis system. Two methods have been used to deduce hourly temperatures from extremes and compared to real observations. The results have shown that using those new pseudo-observations as an input for two different reanalysis systems enables reducing the bias in temperature analysis.

Anomalous light absorption around subwavelength apertures in metal films

In this Letter, we study the heat dissipated at metal surfaces by the electromagnetic field scattered by isolated subwavelength apertures in metal screens. In contrast to the common belief that the intensity of waves created by local sources should decrease with the distance from the sources, we reveal that the dissipated heat at the surface remains constant over a broad spatial interval. This behavior that occurs for noble metals at near infrared wavelengths is observed with nonintrusive thermoreflectance measurements and is explained with an analytical model, which underlines the intricate role played by quasicylindrical waves in the phenomenon. Additionally, we show that, by monitoring the phase of the quasicylindrical waves, the total heat dissipated at the metal surface can be rendered substantially smaller than the heat dissipated by the launched plasmon. This interesting property offers an alternative to amplification for overcoming the loss issue in miniaturized plasmonic devices.

Efficient and intuitive method for the analysis of light scattering by a resonant nanostructure

We present a semi-analytical formalism capable of handling the coupling of electromagnetic sources, such as point dipoles or free-propagating fields, with various kinds of dissipative resonances with radiation leakage, Ohmic losses or both. Due to its analyticity, the approach is very intuitive and physically-sound. It is also very economic in computational resources, since once the resonances of a plasmonic or photonic resonator are known, their excitation coefficients are obtained analytically, independently of the polarization, frequency or location of the excitation source. To evidence that the present formalism is very general and versatile, we implement it with the commercial software COMSOL, rather than with our in-house numerical tools.

Atypical depression and alcohol misuse are related to the cardiovascular risk in the general population

OBJECTIVE

The aims of the present study were to assess the associations between mood, anxiety and substance use disorders, including their subtypes, and the prevalence of cardiovascular risk factors (CVRFs).

METHOD

Thorough physical investigations, biological measures and standardized interview techniques were used to assess 3716 subjects of an urban area, aged 35-66 years.

RESULTS

Atypical depression was associated with increased prevalence of overweight, diabetes and the metabolic syndrome (OR = 1.5, 95% C.I. 1.1-2.0; OR = 2.0, 95% C.I. 1.1-3.5, OR = 1.6, 95% C.I. 1.0-2.4 respectively), whereas decreased prevalence of overweight was found in melancholic (OR = 0.7, 95% C.I. 0.6-0.9) and unspecified depression (OR = 0.8, 95% C.I. 0.7-1.0). Alcohol abuse was associated with diabetes (OR = 1.8, 95% C.I. 1.1-2.9) and dyslipidemia (OR = 1.3, 95% C.I. 1.0-1.8), alcohol dependence with dyslipidemia only (OR = 1.4, 95% C.I. 1.0-2.0). Almost all mental disorders were associated with a lifetime history of regular cigarette smoking, and atypical depression, alcohol misuse and drug dependence were associated with inactivity.

CONCLUSION

To conclude results emphasize the need to subtype depression and to pay particular attention to the atypical subtype. Comorbid alcohol misuse may further increase the cardiovascular risk. Efforts to diminish smoking in subjects with mental disorders could be crucial measures to reduce their high incidence of cardiovascular disease.

Myocardial injury secondary to ICD shocks: insights from patients with lead fracture

BACKGROUND

Patients who receive appropriate implantable cardioverter defibrillator (ICD) shocks have a subsequent adverse prognosis. Most data suggest that patients with inappropriate ICD shocks also have a subsequent adverse prognosis, although this is more controversial. The shocks may be an epiphenomenon, that is, a marker of underlying disease progression; however, it cannot be excluded that shocks cause direct myocardial damage. This latter question is difficult to clarify as the arrhythmia provoking the shock can also cause troponin release. Inappropriate shocks secondary to lead fracture are an ideal situation to examine this question; any troponin release in an otherwise well and hemodynamically stable patient, is likely due directly to the shocks.

METHODS

All patients with Fidelis lead fracture admitted to our institution with inappropriate shocks were included in this study. Troponin (I or T) was considered positive if the level was above the 99th percentile reference cutoff.

RESULTS

Elevated troponin levels were recorded in 16 of 22 patients (73%). Patients with elevated troponin received a higher number of shocks (20.3 ± 30.1 vs 5.3 ± 4.8, P = 0.07) compared with patients with normal troponin. Very elevated troponin levels (>0.8 mcg/L) were seen in five of 22 (22%) patients. The mean peak troponin level for these five patients was 7.06 ± 8.56 mcg/L; two patients had troponin levels that would be expected from a medium-sized myocardial infarction or severe myocarditis.

CONCLUSION

Troponin elevation occurred in the majority of our patients after inappropriate ICD discharges secondary to lead fracture. This indicates that ICD shocks can cause myocardial injury.

Derivation and Validation of a Simple Exercise-Based Algorithm for Prediction of Genetic Testing in Relatives of LQTS Probands

Background—

Genetic testing can diagnose long-QT syndrome (LQTS) in asymptomatic relatives of patients with an identified mutation; however, it is costly and subject to availability. The accuracy of a simple algorithm that incorporates resting and exercise ECG parameters for screening LQTS in asymptomatic relatives was evaluated, with genetic testing as the gold standard.

Methods and Results—

Asymptomatic first-degree relatives of genetically characterized probands were recruited from 5 centers. QT intervals were measured at rest, during exercise, and during recovery. Receiver operating characteristics were used to establish optimal cutoffs. An algorithm for identifying LQTS carriers was developed in a derivation cohort and validated in an independent cohort. The derivation cohort consisted of 69 relatives (28 with LQT1, 20 with LQT2, and 21 noncarriers). Mean age was 35±18 years, and resting corrected QT interval (QTc) was 466±39 ms. Abnormal resting QTc (females ≥480 ms; males ≥470 ms) was 100% specific for gene carrier status, but was observed in only 48% of patients; however, mutations were observed in 68% and 42% of patients with a borderline or normal resting QTc, respectively. Among these patients, 4-minute recovery QTc ≥445 ms correctly restratified 22 of 25 patients as having LQTS and 19 of 21 patients as being noncarriers. The combination of resting and 4-minute recovery QTc in a screening algorithm yielded a sensitivity of 0.94 and specificity of 0.90 for detecting LQTS carriers. When applied to the validation cohort (n=152; 58 with LQT1, 61 with LQT2, and 33 noncarriers; QTc=443±47 ms), sensitivity was 0.92 and specificity was 0.82.

Conclusions—

A simple algorithm that incorporates resting and exercise-recovery QTc is useful in identifying LQTS in asymptomatic relatives.

Child and parental surveys about pre-hospitalization information provision

BACKGROUND

There is little available information about what children and parents would like to know about a forthcoming hospitalization and what they currently receive.

METHODS

The current study was a survey of 102 children between the ages of 6 and 10 years and their parents recruited either from the Recovery Unit following day surgery or from the wards following overnight admissions at Sydney Children's Hospital, Australia. Information was obtained about each child's experience in hospital, the nature and format of information that they had received prior to the admission, and what information the child/parent thought would be helpful to receive.

RESULTS

Parents recorded a total of 163 questions asked by children prior to their admission. Questions related to timing (e.g. duration of admission, length of procedure), pain, procedural information, anaesthesia, needles, whether parents can be present, activities to do in hospital, seeking explanations ('Why' questions), hospital environment, seeking reassurance and miscellaneous questions. Children who were satisfied with the amount of information they received before coming to hospital subsequently reported that they would be significantly less scared should they need to come back to hospital for a future procedure. A total of 46.7% of children received information about their hospitalization from their parent(s) and a further 12% from a doctor and parent.

CONCLUSIONS

Children were found to have many questions about a forthcoming hospitalization. Parents were found to have a major role as information providers. Further research is needed to assess parental confidence and competence to meet their child's information needs.

FC21-06 - Schizophrenia after the 1941 farhud (a pogrom in IRAQ); a study of 6,781 IRAQI-born men and women observed as parents in the jerusalem cohort

Introduction

Maternal stress during pregnancy has been associated with schizophrenia in some settings with evidence suggesting that male and female offspring might be affected differently.

Objectives/aims

In an outbreak of violence in 1941, at least 180 Jews died in Baghdad; rapes, beatings and property damage injured hundreds more in other towns. We questioned whether this stress might be reflected in any change in schizophrenia incidence in people born in 1941.

Methods

We studied admissions to psychiatric hospitals in 39,606 men and 41,208 women, parents of the population-based Jerusalem cohort. We used proportional hazards models to estimate relative incidence of schizophrenia in various groups, over time. Subjects were followed from age in 1950 or immigration, till age at first hospital admission, death or 2004. Schizophrenia was defined by discharge diagnosis, ICD-10 = F20–F29 at any hospital event. Models controlled for secular and cyclic time trends.

Results

For all years combined, the 3,679 male immigrants from Iraq showed a schizophrenia incidence similar to other men (relative risk RR = 0.92, 95% confidence limits 0.67–1.26). But for 141 men born in Iraq in 1941, RR = 4.12 (1.67–10.2, p = .0021 based on 6 cases), compared with men from Iraq born in all other years. Among other men, RR for 1941 births was 1.21 (0.78–1.88,). Women from Iraq showed no significant findings.

Conclusions

These findings enlarge on long-term consequences of ethnic violence. They raise intriguing questions about the relative resilience of the sexes, but should be interpreted cautiously, given that all subjects in this cohort had been able to reproduce.

[Grading of adults primitive glial neoplasms using arterial spin-labeled perfusion MR imaging]

PURPOSE

We investigated the relationship between tumor blood-flow measurement based on perfusion-imaging by arterial spin-labeling (ASL) and histopathologic findings in adults' primitive glial tumours.

PATIENTS AND METHODS

Thus, 40 primitive brain tumors (8 low-grade and 32 high-grade gliomas according to the Sainte-Anne classification) were imaged using pulsed (n=19) or continuous (n=21) ASL. Relative cerebral blood flow (rCBF=tumoral blood flow/normal cerebral blood flow) between high- and low-grade gliomas were compared.

RESULTS

Using pulsed ASL, differences in mean rCBF were observed in high- and low-grade gliomas although no significant (respectively 1.95 and 1.5). Using continuous ASL, mean rCBF were significantly higher for high-grade than for low-grade gliomas (P<0.05). High-grade gliomas could be discriminated using a CBF threshold of 1.18, with a sensitivity of 88%, specificity of 60%, predictive positive value of 88%, and predictive negative value of 60%.

CONCLUSION

ASL-based perfusion provides a quantitative, non-invasive alternative to dynamic susceptibility contrast perfusion MR methods for evaluating CBF. ASL is a suitable method for gliomas initial staging and could be useful to identify intermediate tumoral evolution.

Age, sex and first treatment of schizophrenia in a population cohort

OBJECTIVE

Schizophrenia affects men more than women, but this may not be true at all ages. This study examines the incidence of first hospitalization for treatment of schizophrenia in each sex over different ages.

METHODS

We compared the incidence of first admission for treatment in a cohort of 46,388 males and 43,680 females followed from birth until ages 29-41, using life tables and proportional hazards methods.

RESULTS

Life table estimates of cumulative incidence by age 40 were 1.44% in males and 0.86% in females. For over all ages the relative risk (RR) in males was 1.6 (95% confidence limits=1.4-1.8) compared with females. Before age 17 there was no significant difference between the sexes (RR=0.86, 0.56-1.3). Excess risk in males was observed only from age 17 (RR=1.7, 1.4-1.9). There was no evidence of the incidence in females catching up with that in males, during the 30s.

CONCLUSION

In this population, there was a significant change, over age, in the relative incidence of first hospitalization for schizophrenia between the sexes; the excess incidence in males first developed at age 17.

Pharmacological treatment of primary chronic venous disease: rationale, results and unanswered questions

AIM

The aim of this article was first to review the complex pathophysiological mechanisms responsible for symptoms and signs of primary chronic venous disease (CVD) that allow the identification of targets for pharmacological treatment. The results of CVD treatment with venoactive drugs (VADs) were emphasised and presented in the form of recommendations. The last section raises key questions to be answered to improve protocols for good clinical trials and to draw up future guidelines on these agents.

METHODS

The literature has been reviewed here using PubMed and Embase.

RESULTS

Venous hypertension appears to underlie all clinical manifestations of primary CVD. Inflammation is key in wall remodelling, valve failure and subsequent venous hypertension. Changes in the haemodynamics of veins are transmitted to the microcirculation, resulting in capillary alteration leading to oedema, skin changes and eventually venous ulceration. Venous symptoms may be the result of interplays between pro-inflammatory mediators and nerve fibres located in the venous wall. Therefore, venous inflammation constitutes a promising therapeutic target for pharmacological intervention, and some available VADs could attenuate various elements of venous inflammation. Based on recent studies, reviews and guidelines, tentative recommendations for the use of VADs were proposed and strong recommendations were given to two of them (micronised purified flavonoid fraction and oxerutins).

CONCLUSION

VADs should be accorded a better role in the management of CVD. However, larger and more definitive clinical trials are needed to improve the existing recommendations.

[Patient safety and root cause analysis]

Safety in the field of transfusion medicine has greatly improved in France. The risk of viral transmission has decreased by a factor greater than 1500 within the last 20 years. In comparison, the risk related to ABO error has decreased only by half. The reporting of critical incidents, which occur at any step of the transfusion procedure is now mandatory in France and is subject to an in-depth analysis, using methods close to that used in aviation safety. The goal of these analyses is to better understand human factors in order to implement more adequate prevention measures.