Intraoperative and postoperative findings in children with myringotomy tubes (MT) undergoing cochlear implantation (CI).

OBJECTIVE: To evaluate and compare children undergoing cochlear implantation (CI) with myringotomy tubes (MT) placed preoperatively or intraoperatively to those without MT . METHODS: This was a retrospective review of pediatric patients undergoing CI between 2015 to 2020 at a tertiary care pediatric hospital. CI patients with and without MT were reviewed for the following outcomes: intraoperative findings, intraoperative and postoperative complications, and surgical time. Descriptive and bivariable statistical analysis was performed. RESULTS: 192 cochlear implant surgeries were included: 116 without MT tubes and 76 with a history of MT. Twenty-six patients had MT present at the time of CI surgery. No statistical difference existed between patients with MT (CI + MT group) and those without MT (CI - MT group) with regard to intraoperative complications (P = 0.760) and intraoperative findings (P = 0.545). MT association with total post-operative complications (GEE) showed no statistical significance (OR 2.45, 95% CI 0.83-7.22, P-value 0.105). CI + MT patients were significantly more likely to have inflamed middle ear mucosa at time of surgery (P = 0.003). CI + MT patients did not have a longer length of surgery compared to the CI - MT group (3.47 h vs 3.3 h, respectively, P = 0.342). CONCLUSION: Our data confirms it is safe to perform CI in ears with myringotomy tubes, although the surgeon should be aware of possibly encountering increased middle ear inflammation during the surgery.

The safety of respiratory positive pressure support immediately following pediatric tonsillectomy.

INTRODUCTION: Adenotonsillectomy is the first-line treatment for pediatric obstructive sleep apnea (OSA). The postoperative course may be complicated by hypoxia, requiring intervention. Positive pressure respiratory support (PPS) could be used to bridge the postoperative period and avoid invasive mechanical ventilation; however, the safety of PPS following tonsillectomy has not been established. Objective To review the incidence of complications and risk factors associated with PPS use immediately after tonsillectomy. METHODS: A retrospective cohort study between 2015 and 2020 of patients who underwent tonsillectomy and were admitted to the pediatric intensive care unit at a single healthcare system. RESULTS: Seven hundred eighty patients met inclusion criteria, including 101 patients treated with PPS immediately following surgery. A similar number of patients were diagnosed with severe OSA in each group prior to surgery. One patient in the PPS cohort developed pneumomediastinum and pneumothorax. Eleven patients (12%) in the PPS group and 18 patients (2%) in the non-PPS group developed life-threatening complications, defined as pneumothorax/pneumomediastinum, re-intubation, post-tonsillectomy bleeding that required surgical intervention, pulmonary edema and death, and all occurred in patients who had not used PPS at baseline. Regression analysis identified body mass index, surgical technique, and PPS use to be associated with increased odds of life-threatening complications. CONCLUSION: Our study suggests that PPS is generally safe to use. New-onset PPS is associated with increased odds of life-threatening complications, likely reflecting a severe post-surgical clinical course.

Incidence and Risk Factors Associated with Respiratory Compromise in Planned PICU Admissions Following Tonsillectomy.

OBJECTIVES: Review the incidence and factors associated with respiratory compromise requiring intensive care unit level interventions in children with planned admission to the pediatric intensive care unit (PICU) following tonsillectomy or adenotonsillectomy (T/AT). STUDY DESIGN: Retrospective cohort study. METHODS: Review of all patients with PICU admissions following T/AT from 2015 to 2020 at a tertiary care pediatric hospital. Patient demographics, underlying comorbidities, operative data, and respiratory complications during PICU admission were extracted. RESULTS: Seven hundred and seventy-two patients were admitted to the PICU following T/AT, age 6.1 ± 4.6 years. All children were diagnosed with obstructive sleep apnea or sleep-disordered breathing (mean pre-operative apnea-hypopnea index 29 ± 26.5 and O2 nadir 77.1% ± 11.1). Neuromuscular disease, enteral feed dependence, and obesity were common findings (N = 240 (31%), N = 106 (14%), and N = 209 (27%) respectively). Overall, 29 patients (3.7%) developed respiratory compromise requiring PICU-level support, defined as new-onset continuous or bilevel positive airway pressure support (n = 25) or reintubation (n = 9). Three patients were diagnosed with pulmonary edema. Multivariable regression analysis demonstrated pre-operative oxygen nadir and enteral feed dependence were associated with respiratory compromise (OR = 0.97, 95% CI 0.94-0.99, P = .04; OR = 6.3, 95% CI 2.36-52.6, P = .001 respectively). CONCLUSIONS: Our study found respiratory compromise in 3.7% of patients with planned PICU admissions following T/AT. Oxygen nadir and enteral feeds were associated with higher respiratory compromise rates. Attention should be given to these factors in planning for post-operative disposition.

Evaluating obesity as a risk factor for complications after pediatric adenotonsillectomy.

OBJECTIVES: To evaluate associations between childhood obesity and post-adenotonsillectomy complications, informing guidelines for postoperative management. METHODS: The retrospective review assessed outpatient pediatric tonsillectomy/adenoidectomy cases performed at 2 ambulatory surgery centers in 2020. Complications in the recovery unit and within 2 weeks of surgical discharge were reviewed along with clinical and demographic variables. Obesity was defined as sex-specific body mass index-for-age, or weight-for-age if height data were unavailable, at/above the 95th percentile. The 99th percentile served as the threshold for severe obesity. Analyses used Chi-square/Fisher's exact tests and independent-samples t-tests with relative risk or effect sizes. RESULTS: The review included 707 cases (180 patients with obesity). Overall incidence of complications in the recovery unit was 9.1%. Patients with obesity were significantly more likely to require supplemental blow-by oxygen (P = .02); relative risk was 1.65 (95% CI: 1.16-2.35) times greater in the cohort with obesity. Obesity had a small effect on postoperative oxygen saturation nadirs, which were significantly lower among patients with obesity (d = -0.34; P < .001). No differences emerged between cohorts with and without obesity in the incidence of any other complications before or after surgical discharge. Overall incidence of post-discharge returns was 7.9%. Incidence of complications did not vary by obesity severity. CONCLUSION: From this cohort, childhood obesity without other significant comorbidities may not warrant routine inpatient care following adenotonsillectomy. Patients with obesity should receive additional monitoring for oxygen desaturation events during the first hours of recovery. Further prospective studies should continue to address this important topic.

The utility of preoperative echocardiography in pediatric obstructive sleep apnea.

PURPOSE: The purpose of this study was to determine the associations between cardiac function and postoperative adverse events in pediatric patients with obstructive sleep apnea (OSA). METHODS: Patients between birth and 18 years of age diagnosed with OSA between January 1, 2015, and December 31, 2018, who underwent echocardiographic evaluation within 6 months of surgery at a tertiary care children's hospital were evaluated. Exclusion criteria included history of neuromuscular disorders, tracheostomy placement, or a predominance of central apneic events recorded during polysomnography (PSG). Patients were grouped by OSA severity. Chi-squared analysis and logistic regression were utilized to determine associations between demographic characteristics, OSA severity, preoperative echocardiographic abnormalities, and postoperative adverse events. RESULTS: One hundred ten children met inclusion criteria for the study, including 22 with mild OSA, 22 with moderate OSA, and 66 with severe OSA. Race and the presence of congenital heart disease (CHD) were significantly associated with differences in OSA severity. Echocardiographic abnormalities were found in 45 patients, but exclusion of patients with CHD revealed no significant associations with differences in OSA severity. Postoperative adverse events were identified in 18 (16%) patients, and only O2 saturation nadir was found to be a significant predictor of these complications. CONCLUSION: Preoperative echocardiogram abnormalities are not commonly found in children with OSA and presence of abnormalities does not predict postoperative adverse events. O2 saturation nadir measured on preoperative PSG is a significant predictor of postoperative adverse events and should be examined as a clinical indicator of OSA severity.

Feeding outcomes after paediatric cardiothoracic surgery: a retrospective review.

BACKGROUND: Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes. METHODS: In this retrospective chart review, patients aged 0-18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay. RESULTS: Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge. DISCUSSION: Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.

Attentional ERPs distinguish aging and early Alzheimer's dementia.

The early detection of Alzheimer's disease requires our distinguishing it from cognitive aging. Here, we test whether spatial attentional changes might support that distinction. We engaged young normal (YN), older normal (ON), and patients with early Alzheimer's dementia (EAD) in an attentionally cued, self-movement heading discrimination task while we recorded push-button response times and event related potentials. YNs and ONs show the behavioral effects of attentional shifts from the cue to the target, whereas EAD patients did not (p < 0.001). YNs and ONs also show the shifting lateralization of a newly described attentional event related potentials component, whereas EAD patients did not (p < 0.001). Our findings suggest that spatial inattention in EAD patients may contribute to heading direction processing impairments that distinguish them from ONs and undermine their navigational capacity and driving safety.

Accuracy of Femoral Head and Neck Excision via a Craniolateral Approach or a Ventral Approach.

OBJECTIVES: This study aimed to compare the completeness of femoral head and neck removal via a craniolateral approach or a ventral approach when femoral head and neck excision (FHNE) is performed by a novice veterinarian. METHODS: FHNE was performed on both femurs of 10 canine cadavers with each femur randomized by a coin toss to FHNE via the craniolateral or ventral approach. Computed tomography (CT) of the femurs was performed prior to and following FHNE. The volume of bone that should have been removed with an ideal FHNE, the percentage of this volume that remained following FHNE, time to complete the procedure and the number of technical errors were compared between the two groups. RESULTS: No significant difference (p = 0.88) was found in the volume of bone that should have been removed with an ideal ostectomy when using the two approaches (craniolateral 3,814.7 ± 409.4 mm3; ventral 3,806.2 ± 479.4 mm3), mean excess residual femoral neck (craniolateral 6.0 ± 9.6%; ventral 4.8 ± 6.8%), mean duration of the procedure (craniolateral 19.3 ± 5.4 minutes; ventral 23.7 ± 5.6 minutes) or number of technical errors (craniolateral 0/10; ventral 1/10) between the craniolateral and ventral approach groups. CLINICAL RELEVANCE: The completeness of bone removal was not significantly different when FHNE was performed by a novice veterinarian via a craniolateral or ventral approach.

Navigational path integration by cortical neurons: origins in higher-order direction selectivity.

Navigation relies on the neural processing of sensory cues about observer self-movement and spatial location. Neurons in macaque dorsal medial superior temporal cortex (MSTd) respond to visual and vestibular self-movement cues, potentially contributing to navigation and orientation. We moved monkeys on circular paths around a room while recording the activity of MSTd neurons. MSTd neurons show a variety of sensitivities to the monkey's heading direction, circular path through the room, and place in the room. Changing visual cues alters the relative prevalence of those response properties. Disrupting the continuity of self-movement paths through the environment disrupts path selectivity in a manner linked to the time course of single neuron responses. We hypothesize that sensory cues interact with the spatial and temporal integrative properties of MSTd neurons to derive path selectivity for navigational path integration supporting spatial orientation.

Comparison of restoratively projected and surgically acceptable virtual implant position for mandibular overdentures.

PURPOSE: To compare differences between restoratively projected and surgically acceptable virtual implant positions at sites identified by cylindric radiopaque markers on diagnostic templates for implant-retained mandibular overdentures using cone beam computed tomography (CBCT). MATERIALS AND METHODS: A retrospective chart audit of a CBCT database identified 77 subjects who had been imaged to assess the residual alveolar ridge in the completely edentulous mandible prior to implant placement for mandibular overdentures. Individuals had been scanned with a diagnostic template using cylindric markers to identify the restoratively derived locations and trajectories for implants. Qualitative and quantitative differences between restoratively projected and surgically acceptable positions on transaxial CBCT images were recorded using implant planning software based on a standard implant. RESULTS: Only 6.4% of restoratively projected positions were within the criteria for surgically acceptable implant placement. However, most implant placement plans (77.9%) could be modified to fulfill surgically acceptable criteria. Of the projected implant positions, 15.7% were deemed inadvisable because of potential anatomical complications. Restoratively projected implant position was more likely to deviate buccally than lingually to the available residual alveolar ridge, as determined by CBCT. The mean angular deviation of the clinical prediction from ideal was 14.0 ± 5.5 degrees, the mean platform translation was 2.1 ± 1.3 mm, and the mean apex translation was 2.3 ± 1.5 mm. The average residual alveolar ridge reduction required in the posterior segment was 3.9 ± 2.5 mm. CONCLUSION: The restoratively projected trajectory for implant placement determined by visual inspection, diagnostic casts, and panoramic radiography deviated from the surgically acceptable location determined using CBCT data sets.

A randomized study of transendocardial injection of autologous bone marrow mononuclear cells and cell function analysis in ischemic heart failure (FOCUS-HF).

BACKGROUND: Autologous bone marrow mononuclear cell (ABMMNC) therapy has shown promise in patients with heart failure (HF). Cell function analysis may be important in interpreting trial results. METHODS: In this prospective study, we evaluated the safety and efficacy of the transendocardial delivery of ABMMNCs in no-option patients with chronic HF. Efficacy was assessed by maximal myocardial oxygen consumption, single photon emission computed tomography, 2-dimensional echocardiography, and quality-of-life assessment (Minnesota Living with Heart Failure and Short Form 36). We also characterized patients' bone marrow cells by flow cytometry, colony-forming unit, and proliferative assays. RESULTS: Cell-treated (n = 20) and control patients (n = 10) were similar at baseline. The procedure was safe; adverse events were similar in both groups. Canadian Cardiovascular Society angina score improved significantly (P = .001) in cell-treated patients, but function was not affected. Quality-of-life scores improved significantly at 6 months (P = .009 Minnesota Living with Heart Failure and P = .002 physical component of Short Form 36) over baseline in cell-treated but not control patients. Single photon emission computed tomography data suggested a trend toward improved perfusion in cell-treated patients. The proportion of fixed defects significantly increased in control (P = .02) but not in treated patients (P = .16). Function of patients' bone marrow mononuclear cells was severely impaired. Stratifying cell results by age showed that younger patients (≤60 years) had significantly more mesenchymal progenitor cells (colony-forming unit fibroblasts) than patients >60 years (20.16 ± 14.6 vs 10.92 ± 7.8, P = .04). Furthermore, cell-treated younger patients had significantly improved maximal myocardial oxygen consumption (15 ± 5.8, 18.6 ± 2.7, and 17 ± 3.7 mL/kg per minute at baseline, 3 months, and 6 months, respectively) compared with similarly aged control patients (14.3 ± 2.5, 13.7 ± 3.7, and 14.6 ± 4.7 mL/kg per minute, P = .04). CONCLUSIONS: ABMMNC therapy is safe and improves symptoms, quality of life, and possibly perfusion in patients with chronic HF.

Distinct visual motion processing impairments in aging and Alzheimer's disease.

Aging and Alzheimer's disease (AD) are associated with declines in the visual perception of self-movement that undermine navigation and independent living. We studied 214 subjects' heading direction and speed discrimination using the radial patterns of visual motion in optic flow. Young (YA), middle-aged (MA), and older normal (ON) subjects, and AD patients viewed optic flow in which we manipulated the motion coherence, spatial texture, and temporal periodicity composition of the visual display. Aging and AD were associated with poorer heading and speed perception at lower temporal periodicity, with smaller effects of spatial texture. AD patients were particularly impaired by motion incoherence created by adding randomly moving dots to the optic flow. We conclude that visual motion processing is impaired by distinct mechanisms in aging and the transition to AD, implying distinct neural mechanisms of impairment.

Jugular venous oxygenation during hypothermic cardiopulmonary bypass in patients at risk for abnormal cerebral autoregulation: influence of alpha-Stat versus pH-stat blood gas management.

In a prospective, randomized study of cardiac surgical patients at risk for impaired cerebral blood flow autoregulation, we compared alpha-stat and pH-stat blood gas management. The 40 patients enrolled had age >70 yr, diabetes, prior stroke, or uncontrolled hypertension. During hypothermia and early rewarming, jugular oxygen tensions were significantly lower in alpha-stat patients (n = 12) than pH-stat patients (n = 19; P < 0.05). During rewarming, jugular venous desaturation (i.e., SjvO(2) <50%) occurred in 6 of 12 alpha-stat patients, but no pH-stat patients (P = 0.0006). Patients at risk for poor cerebral autoregulation have higher oxygen tensions and saturations if pH-stat blood gas management is used during cardiopulmonary bypass.

Comparative healing response after sirolimus- and paclitaxel-eluting stent implantation in a pig model of restenosis.

OBJECTIVE: We compared local vessel healing and inflammatory responses associated with nonoverlapping sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). BACKGROUND: Sirolimus and paclitaxel may have different effects on vascular healing. In the present study, we analyzed the local histologic effects of drug-eluting stents (DES). METHODS: We placed 43 stents (22 PES and 21 SES) in 16 Yucatan minipigs. Stents were randomly assigned and placed in the left anterior descending, circumflex, or right coronary arteries (one stent per artery), covering a region previously injured by balloon angioplasty. RESULTS: Histopathologic analysis showed that the distribution of injury scores was similar between the two stent groups, reflecting the homogeneity of coronary injury secondary to balloon overstretch. Electron microscopy showed complete endothelialization in most cases. Incomplete endothelialization was present in 12.5% of PES and almost 20% of SES at 30 days. In the PES group, moderate to severe inflammation was found in eight arteries, whereas only one vessel had moderate inflammation in the SES group. Severe inflammation was observed significantly more often in the PES than in the sirolimus group (P = 0.006). With the PES group, stent struts overlying side branches had a significantly higher frequency of poor endothelialization scores than did stent struts that did not overlay side branches (P = 0.006). CONCLUSIONS: In this preclinical study in a pig model of in-stent restenosis, implantation of nonoverlapping DES was associated with local inflammatory reactions and decreased endothelial repair. Impaired endothelialization was visualized in the struts overlying side branches.

Inflammatory protein levels and depression screening after coronary stenting predict major adverse coronary events.

BACKGROUND: Traditional risk factors cannot account for the majority of future major adverse coronary events (MACE) in patients diagnosed with heart disease. We examined levels of inflammatory proteins to be possible predictors of future MACE and physiological and psychological factors that initiate temporal increases in inflammatory protein levels. METHODS: Peripheral blood samples and depression data were collected 4 to 12 hr after elective coronary stent insertion in 490 patients. Depression screening was assessed by a single-question screening tool. Predictive modeling for future MACE was performed by using survival analysis, with time from the index event (placement of the stent) to future MACE as the dependent variable. RESULTS: Patients with high-sensitivity c-reactive protein (hsCRP) in the second and third quartiles were 3 and 2.5 times more likely to have a MACE than patients with hsCRP in the first quartile, respectively. As levels of vascular cell adhesion molecule and monocyte chemoattractant protein-1 increased, so did the risk of future MACE. Patients who screened positive for depression were approximately 2 times more likely to have a MACE within 24 months after stent placement than were patients who did not screen positive. CONCLUSIONS: Our results suggest that hsCRP, vascular cell adhesion molecule, and monocyte chemoattractant protein-1 levels, measured after coronary stent insertion in patients with coronary heart disease, are prognostic of future MACE. Furthermore, positive depression screening is an independent predictor of future MACE.

Comparison of intracoronary and transendocardial delivery of allogeneic mesenchymal cells in a canine model of acute myocardial infarction.

This study assessed safety of transendocardial (TE) electromechanical-guided delivery of bone marrow mesenchymal stem cells (MSCs) after acute myocardial infarction (AMI) and compared intracoronary (IC) delivery with TE delivery. In a canine acute myocardial ischemia model, 100 x 10(6) MSCs were delivered 7 days after AMI via IC and TE routes. Functional assessment was performed by 2D echocardiogram, and detailed histopathologic analyses were performed to assess the impact of cell therapy in vascular density and fibrosis. Patterns of cell distribution in both delivery methods were also compared. There was a statistically significant reduction in the amount of myocardial ischemia in the TE group (P=0.007). Left ventricular ejection fraction (LVEF) increased 13% (mean) in the TE group (21-day follow-up) and was significantly better than that of the controls (P=0.01), but did not improve in the IC-delivery group. Dissimilar patterns of cell distribution were noted between the IC and TE groups. This study suggests that MSC treatment is probably safe and effective after AMI. In the comparison of TE and IC delivery, the TE group showed higher cell retention (clusters even in the injury center of the infarct) with an increased vascularity and greater functional improvement than did the IC group (no clusters; cells at the border of the infarct). The higher local cell density in the TE group may be important for therapeutic effectiveness.

Regional myocardial deformation in children with hypertrophic cardiomyopathy: morphological and clinical correlations.

AIMS: Hypertrophic cardiomyopathy (HCM) is a disease with marked regional differences in wall thickness. However, the relation between myocardial function and wall thickness has not been well studied. Ultrasonic strain rate (SR) imaging makes it possible to study the regional myocardial deformation. We investigated whether regional systolic deformation is reduced in paediatric patients with HCM and evaluated its relation with wall thickness, electrocardiographic pattern, and exercise capacity. METHODS AND RESULTS: We studied 41 children with asymmetric HCM (mean age 12.3 years) and 29 controls. Electrocardiograms, exercise testing (when feasible), and echocardiograms with tissue Doppler imaging were performed. Peak systolic SR, strain, post-systolic shortening, and time to maximal strain were calculated in the longitudinal direction from the basal septum, mid-septum, and basal lateral myocardial segments and in the radial direction from the basal antero-septal and infero-lateral myocardial segments. Children with HCM had a significant reduction in deformation in all myocardial segments when compared with controls. In the HCM group, peak systolic SR and strain were significantly lower in the basal septum when compared with the mid-septal and basal lateral myocardial segments. In the basal septum, post-systolic shortening was significantly higher and time to maximal strain significantly longer than in mid-septal and lateral myocardial segments. A strong inverse curvilinear relation between peak systolic strain and wall thickness was found (r = -0.86, P < 0.001), with no further decrease in the regional myocardial function demonstrated once maximal wall thickness exceeded a Z-score of 3.5. Peak systolic strain in the basal part of the septum correlated inversely with exercise capacity (r = 0.68, P < 0.01). CONCLUSION: Systolic deformation is significantly and inhomogeneously reduced in children with HCM. This reduction in myocardial function is related to maximal wall thickness and decreased exercise capacity.

The MBL2 'LYQA secretor' haplotype is an independent predictor of postoperative myocardial infarction in whites undergoing coronary artery bypass graft surgery.

BACKGROUND: Mannose-binding lectin (MBL) is an important component of innate immunity and activator of the lectin complement pathway. Within the MBL2 gene are seven 5' "secretor" haplotypes that code for altered serum MBL levels and complement activation. However, recent evidence suggests that 3' MBL2 haplotypes may also modify MBL function and circulating levels. Because MBL and the lectin complement pathway have been implicated in cardiovascular injury, we investigated whether MBL2 haplotypes are independently associated with an increased risk of postoperative myocardial infarction (PMI) in patients undergoing coronary artery bypass graft surgery. METHODS AND RESULTS: Genotyping of 18 polymorphic sites within the MBL2 gene was performed in a prospective, longitudinal multi-institutional study of 978 patients undergoing primary coronary artery bypass graft-only surgery with cardiopulmonary bypass between August 2001 and May 2005. After adjustment for multiple comparisons by permutation testing, multivariate, stepwise logistic regression, including a score test, was performed controlling for patient demographics, preoperative risk factors, medications, and intraoperative variables to determine if MBL2 secretor haplotypes are independent predictors of PMI in whites undergoing primary coronary artery bypass graft surgery. Neither the 5' nor 3' MBL2 haplotypes alone were associated with an increased incidence of PMI. However, the incidence of PMI in whites (n=843) expressing the combined MBL2 5' LYQA secretor haplotype (CGTCGG) and 3' haplotype (CGGGT) was significantly higher than in whites not expressing the haplotype (38% versus 10%; P<0.007). Moreover, the combined MBL2 LYQA secretor haplotype was an independent predictor of PMI in whites after primary coronary artery bypass graft surgery after adjustment for other covariates (P<0.02; adjusted OR: 3.97; 95% CI: 1.30 to 12.07). The combined MBL2 LYQA secretor haplotype in whites was also an independent predictor of postoperative CKMB levels exceeding 60 ng/mL (P<0.02; adjusted OR: 4.48; 95% CI: 1.95 to 16.80). Inclusion of the combined MBL2 LYQA secretor haplotype improved prediction models for PMI based on traditional risk factors alone (C-statistic 0.715 versus 0.705). CONCLUSIONS: The combined MBL2 LYQA secretor haplotype is a novel independent predictor of PMI and may aid in preoperative risk stratification of whites undergoing primary coronary artery bypass graft surgery.

Delayed spinal cord deficits after thoracoabdominal aortic aneurysm repair.

BACKGROUND: Limited information is available about the treatment and outcomes of delayed paraplegia after thoracoabdominal aortic aneurysm (TAAA) repair. The objective of this study was to assess factors that precipitate and favorably affect delayed-onset neurologic deficits. METHODS: Over a 19-year period, 2,368 TAAA repairs were performed. Of the 93 patients (3.9%) who had postoperative paraplegia or paraparesis, 34 (37%) initially had intact neurologic function, but a delayed spinal cord deficit developed. We retrospectively examined clinical factors and events associated with development of the deficits, treatments used, and outcomes. Factors related to functional status were evaluated by comparing survivors who were ambulatory at discharge or transfer with those who were not. RESULTS: The delayed deficits occurred between 13 hours and 91 days postoperatively and were associated with a period of hypotension in 9 patients (26%). Two patients (6%) died in hospital. Of the 32 patients discharged or transferred, 13 (41%) were ambulatory. Poor functional outcomes were associated with female sex, intraoperative cerebrospinal fluid drainage, fewer intercostal arteries reattached, and administration of corticosteroids or osmotic diuretics. The actuarial survival rate at 2 years was 80% +/- 13% for the ambulatory patients and 32% +/- 12% for the nonambulatory patients (p = 0.002). CONCLUSIONS: Although precipitating episodes of hypoperfusion were common, most cases of delayed paraplegia occurred without such events, suggesting that other factors may play an important role in the development of this complication. Ambulatory status at discharge significantly predicts midterm survival.

Left ventricular non-compaction cardiomyopathy in children: characterisation of clinical status using tissue Doppler-derived indices of left ventricular diastolic relaxation.

BACKGROUND: Left ventricular non-compaction (LVNC) may manifest an undulating phenotype ranging from dilated to hypertrophic appearance. It is unknown whether tissue Doppler (TD) velocities can predict adverse clinical outcomes including death and need for transplantation in children with LVNC. METHODS AND RESULTS: 56 children (median age 4.5 years, median follow-up 26 months) with LVNC evaluated at one hospital from January 1999 to May 2004 were compared with 56 age/sex-matched controls. Children with LVNC had significantly decreased early diastolic TD velocities (Ea) at the lateral mitral (11.0 vs 17.0 cm/s) and septal (8.9 vs 11.0 cm/s) annuli compared with normal controls (p<0.001 for each comparison). Using receiver operator characteristic curves, the lateral mitral Ea velocity proved the most sensitive and specific predictor for meeting the primary end point (PEP) at 1 year after diagnosis (area under the curve = 0.888, SE = 0.048, 95% CI 0.775 to 0.956). A lateral mitral Ea cut-off velocity of 7.8 cm/s had a sensitivity of 87% and a specificity of 79% for the PEP. Freedom from death or transplantation was 85% at 1 year and 77% at 2 years. CONCLUSIONS: TD velocities are significantly reduced in patients with LVNC compared with normal controls. Reduced lateral mitral Ea velocity helps predict children with LVNC who are at risk of adverse clinical outcomes including death and need for cardiac transplantation.