Mid-Term Outcome of Mandibular Distraction Osteogenesis in Pierre Robin Sequence.

The aim of the present study was to present a single center's experience with mandibular distraction osteogenesis (MDO) in Pierre Robin sequence (PRS) patients. A retrospective chart review was performed to identify patients with PRS that underwent MDO at our institution from 2003 to 2012. Inclusion criteria were as follows:Evaluation included demographic information, postoperative complications, and surgical outcomes. Twenty-four patients met the inclusion criteria. No complications related to our distraction technique were reported. Most of the patients who had a tracheostomy were successfully decannulated and the rest were able to avoid a tracheostomy. Two patients had superficial infections that were treated conservatively with topical antibiotics. One patient, who was our first case in the series, required 3 episodes of distraction osteogenesis. Another patient demonstrated recurrent symptoms of obstructive sleep apnea after MDO and was treated with continuous positive airway pressure. Over-correction during MDO in PRS is an efficient method for preventing future airway problems. Patients who required a tracheotomy pre-distraction and cases in whom distraction was performed at older age (>2 months of age), had a lower success rate in achieving de-cannulation and a higher rate of complications. Laryngomalacia, gastro-esophageal reflux disease, cardiac, and GI anomalies are not associated with increased failure rates of MDO in PRS.

Atrial Fibrillation and Deterioration in Cognitive Function.

The link between atrial fibrillation and cognitive decline and dementia has gained interest of the medical community lately. More research is being conducted to prevent and or delay this morbidity as no curative therapy is available for cognitive decline and dementia. The exact mechanism of causation is unclear. Multiple pathophysiological mechanisms have been implicated. Lately, treatment for atrial fibrillation including anticoagulation and catheter ablation therapies have shown to decrease the risk of deterioration of cognitive function. In this review we summarize epidemiologic studies linking the association, potential mechanisms, and impact of various modalities of therapy of atrial fibrillation on cognitive function outcomes.

Authors' Response.

Supplemental digital content is available in the text.

Postpartum Coronary Arterial Spasm.

BACKGROUND: Acute coronary syndrome (ACS) during postpartum period is rare. In the current manuscript we present a case of a postpartum patient who developed ACS attributed to coronary vasospasm in the absence of vasocontrictive medication or smoking. This condition resolved with intracoronary injection of nitroglycerine and verapamil. CASE: A 26-year-old woman, postpartum day five, presented with a sudden onset of chest pain and an acute ST-segment elevation on ECG. Coronary artery catheterization showed multiple areas of spasm, which was relieved by intracoronary injection of nitroglycerine and verapamil. Post-catheterization hospital stay was uneventful and the patient was discharged in a stable condition. CONCLUSIONS: Early diagnosis and treatment of ACS in the peripartum period is crucial. Vasospastic coronary disease should be included in the differential diagnosis of peripartum chest pain. Nitrates are still considered the best treatment option with or without calcium channel blockers for both recurrence and prevention.

Why Is Reverse Takotsubo "Reverse"?

OBJECTIVES: Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome simulating myocardial infarction that is characterized by transient wall motion abnormalities in the absence of coronary artery obstruction. Reverse TTC (rTTC) is a recently described variant of TTC. This review defines and compares both forms of TTC, stating their resemblances and differences. METHODS: We conducted a search of the MEDLINE database. Forty-one cases of rTTC met our eligibility criteria and were summarized in a synthesis of the demographic features, clinical characteristics, and laboratory studies. RESULTS: Of the 41 patients studied, 73% were women. Patients' ages ranged from 19 to 69 years and the mean age was 43. The predominant electrocardiogram finding was ST-segment depression, whereas ST-segment elevation was present in only 6 patients (14.5%). Troponin levels were raised in 92.6% of the patients, with a mean troponin I of 7.7 ng/mL. All of the patients had wall motion abnormalities on echocardiography and the mean ejection fraction was 29.3%. Of the 27 patients (66%) who had a documented angiography, 22 (81.5%) had normal coronaries and 5 (18.5%) had minor or mild obstructive coronary artery disease. Of the 41 patients, 9 (22%) died, and the mean recovery time of the ejection fraction in the survivors was 16 days. CONCLUSIONS: rTTC is a distinct presentation from the classic TTC. Remarkable differences exist between both forms in terms of mean age, sex, electrocardiogram presentation, troponin levels, and mortality.

Shorter Door-To-Balloon ST-Elevation Myocardial Infarction Time: Should There Be a Minimum Limit?

In ST-elevation myocardial infarction (STEMI) ischemic time is directly related to permanent myocardial damage and mortality. Therefore, it is crucial to restore myocardial perfusion rapidly. Door-to-balloon (DTB) time is defined as the duration between the arrival time of the patient to the medical facility until the time he or she is treated with percutaneous coronary intervention. Currently, DTB is the criterion that measures the quality of care provided to patients with STEMI at any given institution. It is well documented in the literature that longer DTB is associated with higher mortality; however, lowering DTB beyond current recommendations has not shown to decrease mortality rates. The current recommendations call for a DTB less than 90 minutes from the patient's first contact within the healthcare system, typically the arrival to the emergency department, to the time of the balloon inflation of the culprit coronary artery. Conversely, efforts to keep reducing DTB time may lead to unnecessary percutaneous coronary intervention (in false-positive STEMI) and delay appropriate therapy when needed, possibly missing an alternate potentially life-threatening diagnosis. In conclusion, we herein review the literature on DTB and mortality rate. We also make suggestions about ideal DTB time and hazards of shortening it beyond the recommended guidelines.