Presumed Etiology Research Articles

Clinical characteristics and intracranial arterial lesions of non-young adult ischemic stroke patients with RNF213 p.R4810K variant

BackgroundAlthough RNF213 p.R4810K, a genetic susceptibility variant for moyamoya disease (MMD), is associated with intracranial artery stenosis/occlusion (ICASO), the impact of this variant on ischemic stroke patients in non-young adults is unclear. We aimed to determine the characteristics of non-young adult stroke patients with RNF213 p.R4810K. MethodsWe retrospectively identified acute ischemic stroke patients ≥50 years who were admitted to our hospital and underwent intracranial vascular imaging. We reviewed the patients with RNF213 p.R4810K and compared stroke characteristics and the frequency and location of ICASO between patients with and without the variant. ResultsAmong 341 patients, RNF213 p.R4810K was identified in 7 patients (2.1%). Five of the 7 patients with the variant (71%) had multiple ICASO without any finding of MMD and remaining 2 patients had no ICASO. The presumed etiologies of ICASO were atherosclerosis in 3 cases, vasculitis in 1, and undetermined vasculopathy in 1. ICASO in the anterior circulation was more common in patients with the variant than in those without (71% vs. 25%). The internal carotid artery, the M1 segment of the middle cerebral artery, the A1 segment of the anterior cerebral artery, and the P1 segment of the posterior cerebral artery, which were the most frequently affected arteries in MMD, were more often affected in the variant group. ConclusionsNon-young adult stroke patients with RNF213 p.R4810K are more likely to have ICASO in arterial segments commonly affected in MMD. The etiology of their ICASO exhibited diverse mechanisms, possibly depending on vascular risk and other environmental factors.

Clinical Characterization and Outcomes of Culture- and Polymerase Chain Reaction-Negative Cases of Infectious Keratitis.

To examine the clinical presentation, management, and outcomes of culture and polymerase chain reaction (PCR) negative cases of infectious keratitis. In this retrospective case series, we evaluated the laboratory and medical records of culture- and PCR-negative cases (2016-2020) reported to a tertiary care center, which were presumed to be infectious keratitis on the basis of clinical history and presentation. A total of 121 cases with culture-negative keratitis were included in this study. The mean age of the patients was 48.42 ± 1.89 years, and 53.72% were female. At presentation, the presumed etiology was viral in 38.01%, bacterial in 27.27%, fungal in 8.26%, Acanthamoeba in 6.61%, and unlisted in 28.92% of cases. The most common risk factors were a previous history of ocular surface diseases (96.69%) and contact lens use (37.19%). In total, 61.98% of the patients were already on antimicrobial medication at presentation. The initial management was altered in 79 cases (65.29%) during the treatment course. Average presenting and final (post-treatment) visual acuities (VA) were 0.98 ± 0.04 (LogMAR) and 0.42 ± 0.03 (LogMAR), respectively. A significantly higher frequency of patients with a final VA worse than 20/40 (Snellen) had worse VA at initial presentation (p < 0.0001). A history of ocular surface disease, cold sores, and recurrent infection (p < 0.05) were more commonly associated with a presumed diagnosis of viral keratitis. The patients with presumed bacterial etiology were younger and had a history of poor contact lens hygiene (p < 0.05). We observed a distinct difference in clinical features among patients with culture-negative and PCR-negative keratitis managed for presumed viral and bacterial infections. Although there was significant variability in presentation and management duration in this cohort, the visual outcomes were generally favorable.

Clinical Profile of End Stage Renal Disease Patients Undergoing Hemodialysis in a Tertiary Care Hospital of Nepal

BACKGROUND Maintenance hemodialysis is a popular treatment modality of renal replacement therapy for end stage renal disease patients. The clinical profile of end-stage renal disease (ESRD) and dialysis in Mid Western Nepal are scarce. This study aimed to study the clinical profile of ESRD patients undergoing hemodialysis at the tertiary care Hospital.&#x0D; METHODS This study was a single center based cross sectional observational study carried out over a period from 15th December 2022 to 15th February 2023 in Department of Medicine. A total of 40 patients undergoing maintenance hemodialysis were enrolled in the study. Data about Socio demographic profiles , clinical data, duration of chronic kidney disease (CKD), major comorbidity, the presumed etiology of ESRD, duration of haemodialysis, laboratory parameters including Renal function tests etc were entered in MS Excel and analyzed through SPSS 21.&#x0D; RESULTS A total of 40 patients were enrolled in the study. Males were 25(62.5%) and females were 15(37.5%). The mean age of the patient was 45.75±15.2 years. The most common cause of end stage renal disease and reasons for admission were hypertension nephropathy 36(90%) and Type 2 diabetes mellitus 9(22.5%) respectively. Anemia was the most common hematological findings in ESRD patients (&gt;90%) followed by hypocalcemia in 65%.&#x0D; CONCLUSIONS Hypertensive nephropathy was the commonest cause for CKD followed by diabetic nephropathy and glomerulonephritis. Early detection and effective management of these illnesses can delay the onset, progression of CKD to end stage and subsequent morbidity and the requirement of renal replacement therapy.

Epilepsies of presumed genetic etiology show enrichment of rare variants that occur in the general population

Previous studies suggested that severe epilepsies, e.g., developmental and epileptic encephalopathies (DEEs), are mainly caused by ultra-rare de novo genetic variants. For milder disease, rare genetic variants could contribute to the phenotype. To determine the importance of rare variants for different epilepsy types, we analyzed a whole-exome sequencing cohort of 9,170 epilepsy-affected individuals and 8,436 control individuals. Here, we separately analyzed three different groups of epilepsies: severe DEEs, genetic generalized epilepsy (GGE), and non-acquired focal epilepsy (NAFE). We required qualifying rare variants (QRVs) to occur in control individuals with an allele count≥ 1 and a minor allele frequency ≤ 1:1,000, to be predicted as deleterious (CADD ≥ 20), and to have an odds ratio in individuals with epilepsy ≥ 2. We identified genes enriched with QRVs primarily in NAFE (n= 72), followed by GGE (n= 32) and DEE (n= 21). This suggests that rare variants may play a more important role for causality of NAFE than for DEE. Moreover, we found that genes harboring QRVs, e.g., HSGP2, FLNA, or TNC, encode proteins that are involved in structuring the brain extracellular matrix. The present study confirms an involvement of rare variants for NAFE that occur also in the general population, while in DEE and GGE, the contribution of such variants appears more limited.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology.

Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

PO-02-047 OUTCOMES OF CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICE REMOVAL WITHOUT REIMPLANTATION IN PEDIATRIC PATIENTS

Patients with cardiovascular implantable electronic device (CIED) may no longer meet indications for pacing during follow up. This population represents a challenge for physicians since no guidelines stipulate acceptable indication for CIED removal without reimplantation. Little is known about the risk of significant cardiac events in children who undergo CIED removal. The present study aims to investigate the outcomes in a population having undergone CIED removal without immediate reimplantation before the age of 18 years at our institution. We retrospectively searched for consecutive patients <18 years of age who underwent CIED removal at the Hospital for Sick Children from Jan 2007 to Dec 2022. The primary outcome of significant cardiac event was defined as symptomatic bradycardia with documented high grade atrioventricular block (AVB) or sinus pause, syncope of presumed cardiac origin, ventricular arrhythmia with hemodynamic compromise, or sudden death of presumed arrhythmic etiology. Of 667 patients who underwent CIED implantation at our institution during the study period, a total of 14 (2.1%) patients (9 males [64.3%]) underwent explantation without immediate reimplantation. The majority of patients (N=9; 64.3%) had structural heart disease, with the most common indication for implantation being post-op AVB (N=5; 35.7%) followed by sinus node dysfunction (SND, N=4; 28.6%). During a median follow-up of 2.2 years (IQR 0.4–6.7), significant cardiac event occurred in 3 (21.4%) patients aged 13.5 years (IQR 6.4–17.9) at a median of 0.7 years (IQR 0.6–3.2) after explantation. Two patients had recurrence of their post-operative AVB 7 and 8 months after explantation respectively, both presenting with self-resolving syncope and documented prolonged pause on implantable loop recorder (ILR). One patient known for left atrial isomerism who had been paced for SND developed new complete AVB 3.2 years after his device has been explanted, which represented a new indication for pacing. There were no aborted or sudden death during the 48.7 patient-years of follow-up. In a small cohort of pediatric patients, CIED explantation without reimplantation was a safe practice that required careful patient selection. An ILR should be considered at the time of explant to facilitate monitoring over time. Further studies are required to identify predictive factors for cardiac events in this specific population.

Abstract Number ‐ 265: Reduced‐dose ticagrelor versus full‐dose ticagrelor in patients with stroke: A retrospective cohort study

Introduction There has been an increase in use of ticagrelor in patients with ischemic stroke, particularly in the setting of clopidogrel resistance. Our study aims to retrospectively determine if aspirin plus ticagrelor at a reduced dose is effective in reducing the risk of recurrent stroke and/or other thrombotic events, without increasing the risk of bleeding. Methods In a prospectively maintained database, we performed a retrospective analysis of consecutive patients with acute ischemic stroke in a large academic comprehensive stroke center between September 1, 2020 to July 1, 2022. We compared in‐hospital mortality, 90‐day mortality, favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0 to 2, at 90 days, symptomatic intracranial hemorrhage (sICH), and asymptomatic intracranial hemorrhage (ICH), between patients on reduced‐dose ticagrelor versus those on full‐dose ticagrelor, in unadjusted and adjusted logistic regression models. Results We included 567 patients in our study. The mean age of these patients was 67.0 ± 15.0 years. Females represented 59.5% of the patients, and the majority of the patients were Black (80.0%). Intracranial atherosclerotic disease was the presumed stroke etiology in 96 patients (17.0%). Out of 567 patients, 432 were on a combination of both ticagrelor and aspirin. A total of 62 patients were on a reduced dose of ticagrelor (45 mg or 60 mg twice daily). The remaining 505 patients were on 90 mg twice daily dosing. New or recurrent ischemic stroke was similar across both groups (10.2% vs. 12.0%, p = 0.08). Symptomatic ICH was also found to be similar across both groups (8.2% vs. 9.3%, p = 0.06). Mortality or favorable functional outcome at 90 days also did not differ between the two groups (25.3% vs. 24.7%, p = 0.007; 28.2% vs. 27.3%, p = 0.006). Conclusions A lower dose of ticagrelor (45 or 60 mg twice daily) appears to be a safe and effective regimen in reducing risk of ischemic strokes without increasing hemorrhagic complications when compared to full‐dose ticagrelor at 90 mg twice daily. Further randomized trials are necessary to inform this recommendation.

Anti-NMDAR encephalitis associated with unilateral ovarian teratoma lacking brain component

Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, though rare, is the most common paraneoplastic encephalitis. Typically affecting young female adults, the presumed aetiology is antibody production against the NMDARs of brain tissue within a teratoma.

Is Surgery in Autoimmune Pancreatitis Always a Failure?

Autoimmune pancreatitis is a rare form of chronic pancreatitis of presumed autoimmune etiology. Due to significant overlap in clinical and imaging characteristics, misdiagnosis as a pancreatic malignancy is common. As a result, a significant number of patients undergo a major pancreatic resection, associated with considerable morbidity, for a disease process that generally responds well to corticosteroid therapy. In the past ten years, important advances have been made in understanding the disease. Several diagnostic criteria have been developed to aid in diagnosis. Despite this, pancreatic resection may still be required in a subset of patients to reliably exclude pancreatic malignancy and establish a definite diagnosis of autoimmune pancreatitis. This article aimed to define the role of surgery in autoimmune pancreatitis, if any. For this purpose, published case series of patients with a diagnosis of autoimmune pancreatitis, based on the histopathological examination of surgical specimens, were reviewed and patients' clinical, radiological and serological details were assessed. At the end, histopathologic examinations of patients who underwent pancreatic resection at our department in the last 10 years were retrospectively reviewed in order to identify patients with autoimmune pancreatitis and assess their clinical characteristics.

The prevalence of central retinal vein occlusion was observed in middle age patients with post-covid syndrome multicenter study

Background: The World Health Organization pronounced the Coronavirus disease (COVID-19) a pandemic on March 11, 2020. Patients with COVID-19 are more likely to have multisystem thromboembolic events, such as deep vein thrombosis and pulmonary emboli. This study estimates the clinical characteristics of patients with central retinal vein occlusion (CRVO) post-COVID-19 infection in three governorates of Egypt. Methods: A retrospective randomized study was conducted at Al-Azhar University Hospitals. We revised medical records for patients presented to Ophthalmology departments with CRVO. We considered all patients above 30 years old of both sexes without risk factors for central vein occlusion. Results:Central retinal vein occlusion was observed in post-COVID syndrome at younger ages, rather than the ordinary cases. The most presenting symptoms were fever, dyspnea, and a cough with significant hypoxia and elevated D-dimer level. Conclusion:Our study asserts the importance of more investigation into ocular complications associated with COVID-19. Physicians should be vigilant for acute visual symptoms in COVID-19 patients. Patients presenting with thromboembolism should be screened for COVID-19 infection as a presumed etiology. D-dimer may have an important prognostic value for disease severity. Anti-coagulant medications may be required on a long-term basis after COVID-19 infections.Keywords: acute visual symptoms, ophthalmic evaluation, thromboembolism

Uveitis in the elderly: Clinical and demographic characteristics

AbstractPurpose: To describe clinical characteristics and etiological profile of uveitis presenting for the first time in the elderly and explain its therapeutic challenges and evolutive particularities.Methods: Retrospective review of 170 patients in the department of ophthalmology in Fattouma Bourguiba University Hospital, in the period between January 2007 and January 2021.Results: During the study, 221 eyes of 170 patients were affected by uveitis. The mean age was 59.32 ± 7.32 years and a female gender predominance was registered (61.1% were women). The most prevalent anatomical pattern was anterior uveitis (45/170; 26.4%) followed by panuveitis (33.5%). According to laterality, bilateral involvement (53.6%) was more registered. The majority of cases were chronic (67.2%), acute cases occurred in 31.7%, the rest of the cases (10%) were recurrent. Idiopathic uveitis was diagnosed in 21 cases (12.3%). A definitive or presumed specific aetiology was determined in most of our cases (87.7%), the most common specific aetiology in our case series was sarcoidosis (15.2%) followed by ocular Tuberculosis (12.9%), Herpes simplex virus anterior uveitis (10.5%), and chronic recurrent Vogt‐Koyanagi‐Harada disease (9.4%). An Infectious aetiology was established in 39.4% of the cases and noninfectious systemic autoimmune causes accounted for 24.1%. 53 eyes (16.2%) of 33 patients (19.4%) presented complications during the studied period. The most common ocular complication was uveitic cataract occurring in 38% of the cases.Conclusions: Epidemiological characteristics of uveitis in the elderly population is different from other age categories, which should influence the diagnostic approach in these patients.

Out-of-hospital cardiac arrest complicated by hyperthermia

BackgroundThe aims of this study were to establish epidemiology, clinical management and outcomes in cases of adult out-of-hospital cardiac arrest complicated by hyperthermia attended by the London Ambulance Service NHS Trust between January 2018 and December 2019. Where evidence is available in relation to this sub-set of cardiac arrest patients it is generally limited to small case series and we therefore we sought to improve knowledge and target therapeutic interventions. Methods and resultsRetrospective analysis of 253 cases was undertaken following abstraction from an established cardiac arrest database. Age ranged from 18-99 years with a median of 72 years (IQR 28) and 53.4% (n = 135) of patients were female. Overall thirty-day mortality was 94.5% (n = 239), with 48.2% (n = 122) of patients recognised life extinct in the out-of-hospital phase following termination of resuscitation. No significant differences in clinical characteristics stratified according to temperature group were identified. The presumed aetiology was infective in 62.8% (n = 159) of patients, and due to drug ingestion or heat illness in 7.5% (n = 19) and 2% (n = 5) respectively. In the remaining cases (27.7%, n = 70) it was not possible to determine the likely cause of the arrest. ConclusionsPrevious research relating to cardiac arrest complicated by hyperthermia is limited to case reports and small case series, suggesting that the current study represents the most comprehensive analysis of this sub-group of out-of-hospital cardiac arrest patients currently available. Most cases were associated with evidence of infection compared with drug related aetiologies and heat illness. Where indicated, cooling was applied infrequently using inconsistent methods.

The Dystonias.

This article discusses the most recent findings regarding the diagnosis, classification, and management of genetic and idiopathic dystonia. A new approach to classifying dystonia has been created with the aim to increase the recognition and diagnosis of dystonia. Molecular biology and genetic studies have identified several genes and biological pathways involved in dystonia. Dystonia is a common movement disorder involving abnormal, often twisting, postures and is a challenging condition to diagnose. The pathophysiology of dystonia involves abnormalities in brain motor networks in the context of genetic factors. Dystonia has genetic, idiopathic, and acquired forms, with a wide phenotypic spectrum, and is a common feature in complex neurologic disorders. Dystonia can be isolated or combined with another movement disorder and may be focal, segmental, multifocal, or generalized in distribution, with some forms only occurring during the performance of specific tasks (task-specific dystonia). Dystonia is classified by clinical characteristics and presumed etiology. The management of dystonia involves accurate diagnosis, followed by treatment with botulinum toxin injections, oral medications, and surgical therapies (mainly deep brain stimulation), as well as pathogenesis-directed treatments, including the prospect of disease-modifying or gene therapies.

S3393 Diffuse Large B Cell Lymphoma Presenting as Bleeding and Hypoalbuminemia: A Case Report

Introduction: Diffuse large B cell lymphoma (DLBCL) accounts for 38-57% of primary gastrointestinal (GI) lymphomas. Initial presentation can include nonspecific symptoms, such as weight loss, fatigue, and nausea. Imaging studies are typically nonspecific as well. Therefore, patients are commonly misdiagnosed or diagnosis is delayed. 20-30% of GI lymphomas are in the small intestine but are rarely in the jejunum. We present a rare case of jejunal DLBCL and illustrate the diagnostic difficulties. Case Description/Methods: A 49-year-old male presented with weeks of dizziness, dyspnea, hematochezia, and 30-pound unintentional weight loss over 4 months. Labs were notable for anemia and severe hypoalbuminemia (1.9 g/dL). Esophagogastroduodenoscopy and colonoscopy revealed diverticulosis and hemorrhoids, which were the presumed etiology of his symptoms. One month later, the patient presented similarly. Imaging demonstrated bilateral pulmonary emboli and intramural thickening of the jejunum. For worsening hypoalbuminemia (1.3 g/dL), the patient was scheduled for outpatient work-up. However, he presented again for acute GI bleed and severe anemia. Push enteroscopy revealed patchy mucosal changes in the jejunum and biopsies were consistent with DLBCL. The patient was started on chemotherapy and reported improvement in symptoms and resolution of his GI bleed. Discussion: Primary GI DLBCL is rarely found in the jejunum due to the lack of lymphoid tissue, making this case noteworthy. GI DLBCL is difficult to diagnose, since patients may be asymptomatic or present with nonspecific symptoms. Small intestinal DLBCL can present with GI bleeding, which can easily lead to a misdiagnosis of a diverticular or hemorrhoidal bleed. Imaging studies can be nonspecific and obtaining confirmation through biopsy can prove difficult due to its location, further complicating the diagnosis. One unique aspect of this case that led to the diagnosis was the severity of hypoalbuminemia. The patient was not malnourished, had no clinically apparent protein-losing enteropathy, and no proteinuria or liver failure, making underlying malignancy likely. Differential diagnoses of small bowel wall thickening on imaging is wide and includes infections, primary inflammatory processes such as IBD, and neoplastic lesions. DLBCL may have unusual clinical presentations, subtle laboratory findings and may not be easily diagnosed with initial imaging; thus, clinicians should remain vigilant of this possible diagnosis.

Neglected Temporomandibular Joint In Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic multisystem disease of presumed autoimmune etiology characterized by synovial inflammation that destroys the joint tissue. Although the susceptibility of temporomandibular joint (TMJ) to RA is similar to any other synovial joints in the body, it is generally neglected by the patients without realizing the signs and symptoms of temporomandibular joint disease (TMD). Therefore, it presents a challenge for the Rheumatologists &amp; Dental healthcare personal to suspect and to diagnose TMD in RA at an early stage. The aim of reporting the present case is to highlight the importance of early diagnosis of TMD and thereby reduce the severity of disease which might otherwise collapse the stomatognathic system.

Prevalence of Atherosclerotic Risk Factors Among Children and Young Adults With Arterial Ischemic Stroke

Arterial ischemic stroke (AIS) incidence has decreased overall in recent decades yet has increased in young adults. The potential associations with atherosclerotic risk factors (ARFs) remain unknown. To assess the ages at which ARFs may be risk factors associated with AIS. A nested case-control study was conducted within Kaiser Permanente Northern California (KPNC) from January 1, 2000, through December 31, 2014. Data were analyzed from 2019 to 2022. Cases were identified using diagnostic codes and radiology reports. A total of 2 to 3 controls per case, matched on age and enrollment dates, were randomly identified and confirmed as stroke-free by medical record review. Only ARFs documented prior to stroke diagnosis (or the same date in controls) were considered to ensure the same period of observation. Comparisons were stratified by decade of life. Cases and controls were selected from the KPNC population (4.7 million children and 7.5 million young adults). Medical record review was conducted of all children (aged 29 days to 19 years) and a sample of young adults (aged 20-49 years) with International Classification of Diseases, Ninth Revision code or radiology text string search suggestive of AIS. Stroke-free controls were randomly selected. Hypertension, hyperlipidemia, diabetes, obesity, and smoking history. Odds of AIS. In all analyses, cases and controls were compared using logistic regression. A total of 141 pediatric cases (69 [48.9%] aged 29 days to 9 years; 72 [51.1%] aged 10-19 years) and 364 pediatric controls (168 [46.2%] aged 0-9 years; 196 [53.8%] aged 10-19 years) and 455 young adult cases (71 [15.6%] aged 20-29 years; 144 [31.6%] aged 30-39 years; and 240 [52.7%] aged 40-49 years) and 1018 young adult controls (121 [11.9%] aged 20-29 years; 298 [29.3%] aged 30-39 years; and 599 [58.8%] aged 40-49 years) were identified. The percent of the cases that were male or female did not differ from the percent in the control group. The odds ratio (OR) of having any ARFs on AIS was 1.87 (95% CI, 0.72-4.88) for age range 0 to 9 years; OR, 1.00 (95% CI, 0.51-1.99) for age range 10 to 19 years; OR, 2.3 (95% CI, 1.17- 4.51) for age range 20 to 29 years; OR, 3.57 (95% CI, 2.34-5.45) for age range 30 to 39 years; and OR, 4.91 (95% CI, 3.52-6.86) for age range 40 to 49 years. The risk associated with multiple ARFs was OR, 5.29 (95% CI, 0.47-59.4) for age range 0 to 9 years; OR, 2.75 (95% CI, 0.77-9.87) for age range 10 to 19 years; OR, 7.33 (95% CI, 1.92-27.9) for age range 20 to 29 years; OR, 9.86 (95% CI, 4.96-19.6) for age range 30 to 39 years; and OR, 9.35 (95% CI, 6.31-13.8) for age range 40 to 49 years. The ARF findings by both definitions were significant in all young adult groups. Atherosclerosis was the presumed etiology in 0% of cases in the age group 0 to 9 years, 1.4% in the age group 10 to 19 years, 8.5% in the age group 20 to 29 years, 21.5% in the age group 30 to 39 years, and 42.5% in the age group 40 to 49 years. Although atherosclerosis may not be a common cause of AIS in children or in early young adulthood, findings of this study suggest that ARFs associated with stroke in older adults are present in childhood and increase with age. Efforts to reduce these risk factors should begin as early as possible.

A novel scoring system using easily assessible predictors of return of spontaneous circulation and mortality in traumatic out-of-hospital cardiac arrest patients: A retrospective cohort study

BackgroundAn accident event may necessitate triage of multiple cases of traumatic out-of-hospital cardiac arrest (TOHCA). However, factors for prioritizing treatment among multiple TOHCA patients have not been established. This study aims to use easily assessible predictors of TOHCA outcomes to develop a triage scoring system. MethodsPatients with TOHCA brought to our hospital by emergency medical services (EMS) were included for analysis to identify independent risk factors for poor outcomes. A scoring system was developed and validated internally and externally. ResultsOf the 401 included patients, 86 (21.4%) had return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) for 30 min (81 patients, 94.2%) or 45 min (86 patients, 100%). The emergency department (ED) mortality rate was 89.3% and overall in-hospital mortality rate was 99%. Univariate and multivariate analyses identified body temperature <33 °C (OR, 4.65; 95% CI, 1.37–15.86), obvious chest injury (OR, 2.11; 95% CI, 1.03–4.34), and presumable etiology of out-of-hospital cardiac arrest (OR, 1.73; 95% CI, 1.01–2.98) as significant independent risk factors for non-ROSC. The TOHCA score, calculated as 1 point per risk factor, correlated significantly with the rate of non-ROSC and ED mortality (TOHCA score 0, 1, 2, 3: non-ROSC rate, 63.0%, 80.4%, 90.8%, 100%, respectively; ED mortality rate, 79.5%, 91.5%, 96.1%, and 100% respectively). The results of internal and external validations show a similar trend in both non-ROSC and mortality in the ED with increasing score. ConclusionsTermination of CPR for TOHCA after 45 min is reasonable; a 30-min resuscitation is acceptable in case of insufficient medical staff or resources. The TOHCA score may be able to be used with caution for triage.

Neuromuscular complications after COVID-19 vaccination: a series of eight patients

BackgroundSeveral neurologic complications have been reported in close temporal association with both severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and following vaccination against SARS-CoV-2. Specifically, several cases of Guillain-Barré syndrome (GBS) have been reported in temporal relationship with COVID-19 vaccination, with two small case series describing a specific phenotype with bifacial weakness and paresthesia in the limbs.MethodsWe retrospectively collected patients who developed a new-onset neuromuscular disorder in the first 6 weeks after receiving a COVID-19 vaccine (either first or second dose). The patients were collected from one tertiary care centre and one secondary care centre from February to July 2021.ResultsWe report eight patients who developed phenotypically diverse neuromuscular disorders in the weeks following COVID-19 vaccination, with a presumed immune-mediated etiology. In our case series, we report three patients with classical GBS, one patient with bifacial weakness with paresthesia variant of GBS, two patients with subacute-onset chronic inflammatory demyelinating polyneuropathy (CIDP), one patient with brachial plexopathy and one patient with subacute axonal sensorimotor polyneuropathy.ConclusionsNew-onset neuromuscular disorders with onset in the weeks after COVID-19 vaccination can include diverse phenotypes. A causal relationship between these disorders and the vaccine cannot be proven at present, and further epidemiological studies are needed to further investigate this association.

Trends in bacterial sepsis incidence and mortality in France between 2015 and 2019 based on National Health Data System (Système National des données de Santé (SNDS)): a retrospective observational study

ObjectiveThis study aims to provide a case definition of sepsis of presumed bacterial aetiology based on 10th revision of the International Classification of Diseases (ICD-10) codes, to assess trends in...

Ventricular Arrhythmias and Sudden Death Following Percutaneous Pulmonary Valve Implantation in Pediatric Patients

Reports have suggested a transient increase in ventricular ectopy early after percutaneous pulmonary valve implantation (PPVI). Little is known about the potential for more serious ventricular arrhythmias (VA) in children who undergo PPVI. We sought to evaluate the incidence of severe VA following PPVI in a pediatric population and to explore potential predictive factors. A retrospective cohort study was conducted of patients who underwent PPVI under 20 years of age in our institution from January 2007 to December 2019. The primary outcome of severe VA was defined as sustained and/or hemodynamically unstable ventricular tachycardia (VT), inducible sustained VT, or sudden death of presumed arrhythmic etiology. A total of 21 patients (mean age 16.2 ± 2.1 years; 66.7% male) underwent PPVI. The majority of patients (N = 15; 71.4%) had tetralogy of Fallot (TOF) or TOF-like physiology, with the most common indication being pulmonary insufficiency (N = 10; 47.6%). During a median follow-up of 29.6 months (IQR 10.9–44.0), severe VA occurred in 3 (14.3%) patients aged 15.6 (IQR 14.7–16.1) a median of 12.3 months (IQR 11.2–22.3) after PPVI. All events occurred in patients with TOF-like physiology following Melody valve implant. In conclusion, severe VA can occur long after PPVI in a pediatric population, particularly in those with TOF-like physiology. Further studies are required to elucidate underlying mechanisms and assess strategies to mitigate risks.