Mechanisms of atrial flutter following epicardial high intensity focused ultrasound left atrial ablative procedures during concomitant cardiac surgery

AbstractIntroductionIatrogenic atrial tachyarrhythmias have increased with the widespread application of left atrial ablative procedures to treat atrial fibrillation.Methods and resultsEntrainment and activation mapping were utilized to study the mechanisms of atrial flutter in two patients who presented with atypical atrial flutter after high intensity focused ultrasound (HIFU) atrial ablation for persistent atrial fibrillation during the course of concomitant cardiac surgery. Case 1: Atrial flutter with CL of 340ms was demonstrated to be mediated by entry into and exit from the partially isolated posterior left atrium (LA) with conduction delay across at least one of the connections. The exit site was near the left superior pulmonary vein (LSPV) and the entrance site was near the right inferior pulmonary vein (RIPV) as demonstrated by activation and entrainment mapping. Case 2: Entrainment mapping was highly suggestive of inferior exit from the HIFU ablation line between the two inferior pulmonary veins. Flutter terminated during trans-septal procedure and could not be re-induced. Activation mapping of the LA during pacing revealed the inferior exit and left superior entrance site, both of which were successfully ablated, isolating the posterior LA.ConclusionsRe-entrant atrial flutter post-HIFU epicor Maze is caused by slow conduction at entry and exit sites from the otherwise isolated posterior LA wall. In both cases, gaps were found close to the LSPV and RIPV which may reflect difficulty in achieving proper contact between the HIFU device and the left atrial wall at these sites. These gaps are amenable to catheter ablation

Injury Causes and Severity in Pediatric Traumatic Brain Injury Patients Admitted to the Ward or Intensive Care Unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Background: Traumatic brain injury (TBI) is the leading cause of death and disability in children. It includes a range of different pathologies that differ considerably from adult TBI. Analyzing and understanding injury patterns of pediatric TBI is essential to establishing new preventive efforts as well as to improve clinical management.Methods: The multi-center, prospectively collected CENTER-TBI core and registry databases were screened and patients were included when younger than 18 years at enrollment and admitted to the regular ward (admission stratum) or intensive care unit (ICU stratum) following TBI. Patient demographics, injury causes, clinical findings, brain CT imaging details, and outcome (GOSE at 6 months follow-up) were retrieved and analyzed. Injury characteristics were compared between patients admitted to the regular ward and ICU and multivariate analysis of factors predicting an unfavorable outcome (GOSE 1-4) was performed. Results from the core study were compared to the registry dataset which includes larger patient numbers but no follow-up data.Results: Two hundred and twenty seven patients in the core dataset and 687 patients in the registry dataset were included in this study. In the core dataset, road-traffic incidents were the most common cause of injury overall and in the ICU stratum, while incidental falls were most common in the admission stratum. Brain injury was considered serious to severe in the majority of patients and concurrent injuries in other body parts were very common. Intracranial abnormalities were detected in 60% of initial brain CTs. Intra- and extracranial surgical interventions were performed in one-fifth of patients. The overall mortality rate was 3% and the rate of unfavorable outcome 10%, with those numbers being considerably higher among ICU patients. GCS and the occurrence of secondary insults could be identified as independent predictors for an unfavorable outcome. Injury characteristics from the core study could be confirmed in the registry dataset.Conclusion: Our study displays the most common injury causes and characteristics of pediatric TBI patients that are treated in the regular ward or ICU in Europe. Road-traffic incidents were especially common in ICU patients, indicating that preventive efforts could be effective in decreasing the incidence of severe TBI in children.</div

Age-Related Macular Degeneration in Patients with Androgenetic Alopecia: Could the Monocyte/HDL Ratio Be the Link?

Introduction: Both Androgenetic alopecia (AGA) and age-related macular degeneration (AMD) shared the microinflammatory milieu and increased oxidative stress as important criteria in pathogenesis.   Objectives: To assess the monocyte/High density lipoprotein (HDL) ratio (MHR) in patients with AGA and its correlation to AMD in these patients, if any. Methods: 40 patients with AGA aged 40 years or more of both sexes and 40 control subjects participated in this case-control study. General, dermatological, and ophthalmologic examination, MHR evaluation and optical coherence tomography (OCT) were performed. Results: The mean MHR was significantly higher in AGA patients (6.98 ± 2.21) than controls (3.82 ± 0.68) (p<0.001). AMD was significantly higher in patients than control (p <0.001). 80% of patients were diagnosed with AMD vs 20% of control subjects. Presence of AMD in AGA was significantly related to the degree of severity of AGA in male patients (P= 0.02). MHR was significantly higher in AGA patients found to have AMD (9.37 ± 1.1 and 7.01 ± 1.42 in wet and dry type respectively) than those without AMD (P<0.001). The best cutoff value of MHR in prediction of wet type among patients of AGA is ≥8.2337 with overall accuracy 80%. While the best cutoff value of MHR in prediction of dry type among AGA patients is ≥4.1408 to <8.2337 with overall accuracy 86.7%. Conclusion: AMD may develop more frequently in those with AGA, and this may correspond with the disease's severity. MHR seems to be a missing link between both conditions

Neurosurgical morbidity in pediatric supratentorial midline low‐grade glioma: results from the German LGG studies

Surgical resection is a mainstay of treatment for pediatric low-grade glioma (LGG) within all current therapy algorithms, yet associated morbidity is scarcely reported. As supratentorial midline (SML) interventions are particularly challenging, we investigated the frequency of neurosurgical complications/new impairments aiming to identify their risk factors. Records were retrospectively analyzed from 318 patients with SML-LGG from successive German multicenter LGG studies, undergoing surgery between May 1998 and June 2020. Exactly 537 operations (230 resections, 167 biopsies, 140 nontumor procedures) were performed in 318 patients (54% male, median age: 7.6 years at diagnosis, 9.5 years at operation, 11% NF1, 42.5% optic pathway glioma). Surgical mortality rate was 0.93%. Applying the Drake classification, postoperative surgical morbidity was observed following 254/537 (47.3%) and medical morbidity following 97/537 (18.1%) patients with a 40.1% 30-day persistence rate for newly developed neurological deficits (65/162). Neuroendocrine impairment affected 53/318 patients (16.7%), visual deterioration 34/318 (10.7%). Postsurgical morbidity was associated with patient age <3 years at operation, tumor volume ≥80 cm3, presence of hydrocephalus, complete resection, surgery in centers with less than median reported tumor-related procedures and during the earlier study period between 1998 and 2006, while the neurosurgical approach, tumor location, NF1 status or previous nonsurgical treatment were not. Neurosurgery-associated morbidity was frequent in pediatric patients with SML-LGG undergoing surgery in the German LGG-studies. We identified patient- and institution-associated factors that may increase the risk for complications. We advocate that local multidisciplinary teams consider the planned extent of resection and surgical skills

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration

OBJECTIVE Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. METHODS A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. RESULTS One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3–15.4 years; 22% were \u3c 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28). CONCLUSIONS CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable

Reply to letter to the editor “effect of thrombocytopenia on development of posthemorrhagic hydrocephalus in neonates: few concerns”

Purpose!#!Post-hemorrhagic hydrocephalus (PHH) is a rare but serious complication among premature babies in the neonatal intensive care unit. The causes of PHH are still not entirely understood, and its prevention and treatment are controversial. We tried to analyze the risk factors for such complication in our cohort.!##!Methods!#!We reviewed our neonatology data bank and included all preterms below 28 weeks who were born in the period between 1999 and 2014 and suffered from an intraventricular hemorrhage (IVH). We reviewed gestational age, gender, birth weight, type of birth, IVH degree, comorbidities, therapy, complications, time to event, protein content of cerebrospinal fluid, and clinical follow-up.!##!Results!#!We identified 180 patients, divided into two subgroups, 'B1' with 37 cases (IVH + PHH) and 'B2' with 143 cases (IVH - PHH). In group B1, the presence of IVH grades I, II, III, or IV was in 11%, 19%, and 70% respectively. Nineteen patients were treated with a ventricular access device (VAD) or external ventricular drain (EVD). A total of 20 shunts were implanted, with 11 revisions (55%). One patient suffered from thrombocytopenia. In subgroup B2, 51% showed IVH grade I, whereas severe IVH grades were only present in 22%. 25.9% suffered from thrombocytopenia. Thrombocytopenia was significantly higher in patients who did not develop PHH (p value: 0.002).!##!Conclusion!#!According to our results, thrombocytopenia could play a decisive role in avoiding development of PHH as a sequel of IVH. We recommend a randomized controlled trial to assess the possible efficacy of antiplatelet drugs in avoiding PHH in this vulnerable group

The Value of Lateral Spread Response Monitoring in Predicting the Clinical Outcome after Microvascular Decompression in Hemifacial Spasm: A Prospective Study on 100 patients.

Background: Microvascular Decompression represents an effective treatment for hemifacial spasm. The use of lateral spread responses (LSRs) monitoring remains a useful intraoperative tool to ensure adequate decompression of the facial nerve. Objective: To assess the value of LSRs intraoperative monitoring as a prognostic indicator for the outcome of microvascular decompression in hemifacial spasm. Methods: Our study included 100 patients prospectively. The patients were classified into 4 groups whether LSRs were totally, partially, not relieved or not detected from the start. According to clinical outcome, the patients were classified into 4 groups depending on the clinical course after surgery and the residual symptoms if any. Then, correlations were made between LSRs events and treatment outcome to detect its reliability as a prognostic indicator. Results: LSRs were relieved totally in 56% of the patients, partially relieved in 14%, not relieved in 10% and were not detected in 20% of the patients from the start. HFS was relieved directly after operation in 62% with clinical improvement of 90-100%. 31% described 50-90% improvement over the next 3 months after surgery. Almost all of these 31% (28 out of 31 patients) reported further clinical improvement of 90-100% within one year after surgery. 3% suffered from a relapse after a HFS-free period and 4% reported minimal or no improvement describing 0-50% of the preoperative state. The percentage of the satisfied patients with the clinical outcome who reported after one year a clinical improvement of 90-100% was 90%. Statistical analysis did not find a significant correlation between the relief of LSRs and clinical outcome. Conclusion: LSRs may only represent an intraoperative tool to guide for an adequate decompression but failed to represent a reliable prognostic indicator for treatment outcome.Hintergrund: Mikrovaskuläre Dekompression stellt eine effektive Therapie für Spasmus hemifacialis dar. Die Verwendung von LSRs "lateral spread response" - Monitoring ist weiterhin ein nützliches intraoperatives Instrument, um eine adäquate Dekompression des N. facialis zu gewährleisten. Ziel: Bewertung des Wertes der LSRs intraoperative Überwachung als prognostischer Indikator für das Ergebnis der mikrovaskulären Dekompression in Spasmus hemifacialis. Methoden: Unsere Studie umfasste 100 Patienten prospektiv. Die Patienten wurden in 4 Gruppen eingeteilt, ob LSRs vollständig, teilweise, nicht entlastet oder nicht von Anfang an nachgewiesen wurden. Nach dem klinischen Ergebnis wurden die Patienten in 4 Gruppen je nach klinischem Verlauf nach der Operation und die restlichen Symptome, wenn überhaupt, eingeteilt. Dann wurden Korrelationen zwischen LSRs Ereignisse und die klinischen Ergebnisse analysiert, um seine Zuverlässigkeit als prognostische Indikator zu erkennen. Ergebnisse: LSRs wurden in 56% der Patienten vollständig entlastet, teilweise in 14%, nicht in 10% entlastet und wurden nicht bei 20% der Patienten von Anfang an erkannt. Spasmus hemifacialis wurde direkt nach Operation in 62% mit klinischer Verbesserung von 90-100% erleichtert. 31% beschrieben 50-90% Verbesserung in den nächsten 3 Monaten nach der Operation. Fast alle dieser 31% (28 von 31 Patienten) berichteten weitere klinische Verbesserung von 90-100% innerhalb des ersten postoperativen Jahres. 3% litten an einem Rezidiv nach einer Symptome-freien Periode und 4% berichteten von einer minimalen oder keiner Verbesserung, die 0-50% des präoperativen Zustands beschrieben. Das Prozent der zufriedenen Patienten mit dem klinischen Ergebnis, die nach einem Jahr eine klinische Verbesserung von 90-100% berichteten, betrug 90%. Die statistische Analyse fand keine signifikante Korrelation zwischen der Entlastung der LSRs und dem klinischen Ergebnis. Schlussfolgerung: LSRs können nur ein intraoperatives Instrument darstellen, das zu einer adäquaten Dekompression führt, aber stellt keinen verlässlichen prognostischen Indikator für die langzeitigen klinischen Ergebnisse dar

Trapped fourth ventricle: a rare complication in children after supratentorial CSF shunting

Purpose!#!Trapped fourth ventricle (TFV) is a well-identified problem in hydrocephalic children. Patients with post-hemorrhagic hydrocephalus (PHH) are mostly affected. We tried to find out predisposing factors and describe clinical findings to early diagnose TFV and manage it.!##!Methods!#!We reviewed our database from 1991 to 2018 and included all patients with TFV who required surgery. We analyzed prematurity, cause of hydrocephalus, type of valve implanted, revision surgeries, modality of treatment of TFV, and their clinical examination and MRI imaging.!##!Results!#!We found 21 patients. Most of patients suffered from PHH (16/21), tumor (2/21), post-meningitis hydrocephalus (2/21), and congenital hydrocephalus (1/21). Seventeen patients were preterm. Seven patients suffered from a chronic overdrainage with slit ventricles in MRI. Thirteen patients showed symptoms denoting brain stem dysfunction; in 3 patients, TFV was asymptomatic and in 5 patients, we did not have available information regarding presenting symptoms due to missing documentation. An extra fourth ventricular catheter was the treatment of choice in 18/21 patients. One patient was treated by cranio-cervical decompression. Endoscopic aqueductoplasty with stenting was done in last 2 cases.!##!Conclusion!#!Diagnosis of clinically symptomatic TFV and its treatment is a challenge in our practice of pediatric neurosurgery. PHH and prematurity are risk factors for the development of such complication. Both fourth ventricular shunting and endoscopic aqueductoplasty with stenting are effective in managing TFV. Microsurgical fourth ventriculostomy is not recommended due to its high failure rate. Early detection and intervention may help in avoiding fatal complication and improving the neurological function

Strangles in Arabian horses in Egypt: Clinical, epidemiological, hematological, and biochemical aspects

Aim: Respiratory tract infections are considered the major problem of equine worldwide. Strangles is an infectious and highly contagious respiratory bacterial disease of equine caused by Streptococcus equi. This study is aimed to evaluate some clinical and epidemiological investigation associated with strangles and to study the hematological and biochemical changes in 20 Arabian horses naturally infected with S. equi during the disease and after 10 days from treatment by procaine penicillin with benzathine penicillin. Materials and Methods: A total of 490 Arabian horses have been examined, 120 (24.5%) have been clinically diagnosed as strangles. Under complete aseptic conditions, nasal swabs and pus samples from those were collected for bacterial culture. 20 horses from the positive infected with S. equi have been treated by 6 mg/kg b.wt procaine penicillin with 4.5 mg/kg b.wt benzathine penicillin deep intramuscular injection/twice dose/4 days interval. Results: 102 horses (20.8%) were found positive for S. equi. Horses with age group under 1 year were the most prone to strangles (32.25%) followed by horses of the age group from 1 to 2 years (20%) and finally of the age group over 2-4 years (11.89%). Hematological parameters revealed anemia in the infected horses, while leucogram revealed a significant increase in the total leucocytic, granulocytic and monocytic counts without a significant change in the lymphocytic count. Biochemical parameters revealed a significant increase in serum aspartate aminotransferase, total proteins, globulins, cardiac troponin I (cTnI), and potassium. In other side, hypoalbuminemia and hyponatremia have been reported, whereas alanine aminotransferase activity and creatinine level showed non-significant changes. Respiratory acidosis has been exhibited in the infected horses. Treatment of horses by procaine penicillin with benzathine penicillin revealed improvement of these parameters toward the healthy horses. Conclusion: S. equi easily spreads from infected to susceptible horses through contaminated water and other fomites. Therefore, good biosecurity is very important if the welfare and economic costs of an outbreak are to be reduced. The presence of respiratory acidosis with increased of cTnI could indicate pneumonia secondary to strangles with risk of heart involvement

Thrombocytopenia: is it a prognostic factor for development of post-hemorrhagic hydrocephalus in neonates?

Purpose!#!Post-hemorrhagic hydrocephalus (PHH) is a rare but serious complication among premature babies in the neonatal intensive care unit. The causes of PHH are still not entirely understood, and its prevention and treatment are controversial. We tried to analyze the risk factors for such complication in our cohort.!##!Methods!#!We reviewed our neonatology data bank and included all preterms below 28 weeks who were born in the period between 1999 and 2014 and suffered from an intraventricular hemorrhage (IVH). We reviewed gestational age, gender, birth weight, type of birth, IVH degree, comorbidities, therapy, complications, time to event, protein content of cerebrospinal fluid, and clinical follow-up.!##!Results!#!We identified 180 patients, divided into two subgroups, 'B1' with 37 cases (IVH + PHH) and 'B2' with 143 cases (IVH - PHH). In group B1, the presence of IVH grades I, II, III, or IV was in 11%, 19%, and 70% respectively. Nineteen patients were treated with a ventricular access device (VAD) or external ventricular drain (EVD). A total of 20 shunts were implanted, with 11 revisions (55%). One patient suffered from thrombocytopenia. In subgroup B2, 51% showed IVH grade I, whereas severe IVH grades were only present in 22%. 25.9% suffered from thrombocytopenia. Thrombocytopenia was significantly higher in patients who did not develop PHH (p value: 0.002).!##!Conclusion!#!According to our results, thrombocytopenia could play a decisive role in avoiding development of PHH as a sequel of IVH. We recommend a randomized controlled trial to assess the possible efficacy of antiplatelet drugs in avoiding PHH in this vulnerable group