Effect of Water Precautions on Otorrhea Incidence after Pediatric Tympanostomy Tube: Randomized Controlled Trial Evidence.

OBJECTIVES: Tympanostomy with ventilation tube insertion is the most common otologic surgery. Many surgeons recommend water precautions, although its utility is questioned. We aimed to investigate if water precautions reduce the rate of otorrhea after transtympanic tube insertion. STUDY DESIGN: Multicenter randomized controlled trial. SUBJECTS AND METHODS: A total of 244 children aged 2 to 10 years undergoing their first set of Shepard tubes for otitis media with effusion and concomitant adenoidectomy were randomized to 2 groups: 1 with ear protection during water exposure (ear plugs and headbands, n = 130) and 1 without (n = 114). Bathing or swimming with unprotected ears was considered the exposure event and incidence of otorrhea, the primary outcome. Outcomes were assessed during the 6-month follow-up period. RESULTS: In the water precaution group, 32% had at least 1 episode of otorrhea as compared with 22% in the unprotected group, which was not statistically significant (P = .09). Only 37% of the episodes of otorrhea in the protected group and 36% in the unprotected group had a temporal relation to water exposure (no difference, P = .81). Respectively, 56% and 52% of the episodes of otorrhea were in the context of upper respiratory tract infection. Global quality of life improved significantly, irrespective of whether water protection was prescribed. CONCLUSION: The incidence of otorrhea was not different with or without prescription of ear protection during water exposure among children with tympanostomy tubes, which supports current guideline recommendations that routine water precautions are unnecessary in this population.

Physiological adaptations to chronic stress in healthy humans - why might the sexes have evolved different energy utilisation strategies?

KEY POINTS: The human stress response activates the autonomic nervous system and endocrine systems to increase performance during environmental challenges. This response is usually beneficial, improving the chance of overcoming environmental challenges, but costs resources such as energy. Humans and other animals are known to adapt their responses to acute stress when they are stimulated chronically, presumably to optimise resource utilisation. Characterisation of these adaptations has been limited. Using advanced imaging techniques, we show that cardiovascular and endocrine physiology, reflective of energy utilisation during acute stress, and energy storage (fat) differ between the sexes when they are exposed to chronic stress. We examine possible evolutionary explanations for these differences, related to energy use, and point out how these physiological differences could underpin known disparities between the sexes in their risk of important cardiometabolic disorders such as obesity and cardiovascular disease. ABSTRACT: Obesity and associated diseases, such as cardiovascular disease, are the dominant human health problems in the modern era. Humans develop these conditions partly because they consume excess energy and exercise too little. Stress might be one of the factors contributing to these disease-promoting behaviours. We postulate that sex-specific primordial energy optimisation strategies exist, which developed to help cope with chronic stress but have become maladaptive in modern societies, worsening health. To demonstrate the existence of these energy optimisation strategies, we recruited 88 healthy adults with varying adiposity and chronic stress exposure. Cardiovascular physiology at rest and during acute stress (Montreal Imaging Stress Task), and body fat distribution were measured using advanced magnetic resonance imaging methods, together with endocrine function, cardiovascular energy use and cognitive performance. Potential confounders such as lifestyle, social class and employment were accounted for. We found that women exposed to chronic stress had lower adiposity, greater acute stress cardiovascular responses and better cognitive performance. Conversely, chronic stress-exposed men had greater adiposity and lower cardiovascular responses to acute stress. These results provide initial support for our hypothesis that differing sex-specific energy conservation strategies exist. We propose that these strategies have initially evolved to benefit humans but are now maladaptive and increase the risk of disorders such as obesity, especially in men exposed to chronic stress.

Feasibility and outcomes of ajmaline provocation testing for Brugada syndrome in children in a specialist paediatric inherited cardiovascular diseases centre.

OBJECTIVES: Brugada syndrome (BrS) is an inherited arrhythmia syndrome that causes sudden cardiac death in the young. The class Ia antiarrhythmic ajmaline can be used to provoke the diagnostic ECG pattern. Its use has been established in adults, but little data exist on the ajmaline provocation test in children. This study aims to determine the safety and feasibility of ajmaline provocation testing in a large paediatric cohort in a specialist paediatric inherited cardiac diseases centre. METHODS: 98 consecutive ajmaline tests were performed in 95 children between September 2004 and July 2012 for family history of BrS (n=46 (48%)); family history of unexplained sudden cardiac death (n=39 (41%); symptoms with suspicious ECG abnormalities (n=9 (10%)). Three patients were retested with age, due to the possibility of age-related penetrance. ECG parameters were measured at baseline and during maximal ajmaline effect. RESULTS: The mean patient age was 12.55 years, 43% were female. Nineteen patients (20%) had a positive ajmaline test. There were no arrhythmias or adverse events during testing. Ajmaline provoked significant prolongation of the PR, QRS and QTc in all patients. Mean follow-up was 3.62 years with no adverse outcomes reported in any patients with BrS. There were no predictors of a positive ajmaline provocation test on multivariable analysis. One patient who tested negative at 12 years of age, subsequently tested positive at 15 years of age. CONCLUSIONS: Ajmaline testing appears safe and feasible in children when performed in an appropriate setting by an experienced team. Test positivity may change with age in individuals, suggesting that the test should be repeated in the late teenage years or early adulthood.

Prognostic significance of cardiac magnetic resonance imaging in children with pulmonary hypertension.

BACKGROUND: There are very few validated prognostic markers in pediatric pulmonary hypertension. Cardiac MRI is a useful, noninvasive method for determining prognosis in adults. The present study is the first to assess its prognostic value in children. METHODS AND RESULTS: A total of 100 children with pulmonary hypertension (median, 10.4 years; range, 0.5-17.6 years) were evaluated (idiopathic, n=60; repaired congenital heart disease, n=22; miscellaneous, n=18). In all patients, ventricular volumes and great vessel flow were measured. Volumetric data were obtained using retrospectively gated cine imaging (n=37) or real-time imaging (n=63), depending on the patient's ability to hold his or her breath. During a median follow-up of 1.9 years, 11 patients died and 3 received lung transplantation. Of the cardiac MR parameters measured, right ventricular ejection fraction and left ventricular stroke volume index were most strongly predictive of survival on univariate analysis (2.6- and 2.5-fold increase in mortality for every 1-SD decrease, respectively; P<0.05). These results were reflected in good separation of tertile-based Kaplan-Meier survival curves for these variables. CONCLUSIONS: Cardiac MR measures correlate with clinical status and prognosis in children with pulmonary hypertension. Cardiac MR is feasible and may be useful in clinical decision making in pediatric pulmonary hypertension.

Habitual alcohol consumption is associated with lower cardiovascular stress responses--a novel explanation for the known cardiovascular benefits of alcohol?

In contrast to heavy alcohol consumption, which is harmful, light to moderate drinking has been linked to reduced cardiovascular morbidity and mortality. Effects on lipid status or clotting do not fully explain these benefits. Exaggerated cardiovascular responses to mental stress are detrimental to cardiovascular health. We hypothesized that habitual alcohol consumption might reduce these responses, with potential benefits. Advanced magnetic resonance techniques were used to accurately measure cardiovascular responses to an acute mental stressor (Montreal Imaging Stress Task) in 88 healthy adults (∼1:1 male:female). Salivary cortisol and task performance measures were used to assess endocrine and cognitive responses. Habitual alcohol consumption and confounding factors were assessed by questionnaire. Alcohol consumption was inversely related to responses of heart rate (HR) (r = -0.31, p = 0.01), cardiac output (CO) (r = -0.32, p = 0.01), vascular resistance (r = 0.25, p = 0.04) and mean blood pressure (r = -0.31, p = 0.01) provoked by stress, but not to stroke volume (SV), or arterial compliance changes. However, high alcohol consumers had greater cortisol stress responses, compared to moderate consumers (3.5 versus 0.7 nmol/L, p = 0.04). Cognitive measures did not differ. Findings were not explained by variations in age, sex, social class, ethnicity, physical activity, adrenocortical activity, adiposity, smoking, menstrual phase and chronic stress. Habitual alcohol consumption is associated with reduced cardiac responsiveness during mental stress, which has been linked to lower risk of hypertension and vascular disease. Consistent with established evidence, our findings suggest a mechanism by which moderate alcohol consumption might reduce cardiovascular disease, but not high consumption, where effects such as greater cortisol stress responses may negate any benefits.

Adiposity is associated with blunted cardiovascular, neuroendocrine and cognitive responses to acute mental stress.

Obesity and mental stress are potent risk factors for cardiovascular disease but their relationship with each other is unclear. Resilience to stress may differ according to adiposity. Early studies that addressed this are difficult to interpret due to conflicting findings and limited methods. Recent advances in assessment of cardiovascular stress responses and of fat distribution allow accurate assessment of associations between adiposity and stress responsiveness. We measured responses to the Montreal Imaging Stress Task in healthy men (N = 43) and women (N = 45) with a wide range of BMIs. Heart rate (HR) and blood pressure (BP) measures were used with novel magnetic resonance measures of stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR) and arterial compliance to assess cardiovascular responses. Salivary cortisol and the number and speed of answers to mathematics problems in the task were used to assess neuroendocrine and cognitive responses, respectively. Visceral and subcutaneous fat was measured using T(2) (*)-IDEAL. Greater BMI was associated with generalised blunting of cardiovascular (HR:ß = -0.50 bpm x unit(-1), P = 0.009; SV:ß = -0.33 mL x unit(-1), P = 0.01; CO:ß = -61 mL x min(-1) x unit(-1), P = 0.002; systolic BP:ß = -0.41 mmHg x unit(-1), P = 0.01; TPR:ß = 0.11 WU x unit(-1), P = 0.02), cognitive (correct answers: r = -0.28, P = 0.01; time to answer: r = 0.26, P = 0.02) and endocrine responses (cortisol: r = -0.25, P = 0.04) to stress. These associations were largely determined by visceral adiposity except for those related to cognitive performance, which were determined by both visceral and subcutaneous adiposity. Our findings suggest that adiposity is associated with centrally reduced stress responsiveness. Although this may mitigate some long-term health risks of stress responsiveness, reduced performance under stress may be a more immediate negative consequence.

An unusual case of incomplete Kawasaki disease in an adolescent returning from holiday in Montana.

Here we present an unusual case of incomplete Kawasaki disease in a 15-year-old boy returning from a holiday with his family in Montana. His symptoms were initial diarrhoea and lethargy, with fever, rash, conjunctivitis, and arthralgia developing during the course of his illness. His condition worsened while he was at his local hospital, and he was transferred to the regional tertiary paediatric hospital. An initial echocardiogram was normal; however, repeat echocardiogram showed dilated coronary arteries with subsequent development of peeling of the skin on the hands and feet. The patient was started on intravenous immunoglobulin and high-dose aspirin and improved clinically. He was discharged home and remains under follow-up by the infectious diseases and cardiology teams.

Precipitating factors and patient outcomes in acute kidney injury treated with renal replacement therapy.

Acute kidney injury (AKI) is not uncommon in acute hospital admissions. AKI treated with renal replacement therapy (RRT) has a wide spectrum of causes and the mortality rate at 90 days, approaches 50%. This study was performed to analyse the identifiable causes and outcomes of all cases of AKI treated with RRT in the Glasgow Royal Infirmary (GRI) renal wards during 2007. This study identified 65 cases of AKI treated with RRT from the GRI renal unit electronic patient record (EPR). Causes of AKI, modality of RRT and patient outcomes were retrieved from the EPR and discharge letters. The main outcome measures were the mortality rate and the percentage of patients still receiving RRT at 90 days. More than one precipitating factor was identified in half of the cases of dialysis-dependent AKI. Sepsis, hypovolaemia and nephrotoxic drugs were the main contributory factors and were observed in 52%, 40% and 23% of the cases, respectively. The mortality rate was 29% at 90 days. This study shows that the aetiology of AKI is often multifactorial and the 90-day mortality rate of AKI treated with RRT is still high.