A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study.

BACKGROUND: Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries. METHODS: 592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed. RESULTS: The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed. CONCLUSION: Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

Tachyarrhythmia after the total cavopulmonary connection: incidence, prognosis, and risk factors.

OBJECTIVE: The purpose of this study is to evaluate the incidence and outcomes regarding tachyarrhythmia in patients after total cavopulmonary connection. METHODS: A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 at our institution was performed. Incidence of tachyarrhythmia was depicted, and results after onset of tachyarrhythmia were evaluated. Factors associated with the onset of tachyarrhythmia were identified. RESULTS: A total of 52 (8%) patients presented with tachyarrhythmia that required medical therapy. Onset during hospital stay was observed in 27 patients, and onset after hospital discharge was observed in 32 patients. Freedom from late tachyarrhythmia following total cavopulmonary connection at 5, 10, and 15 years was 97, 95, and 91%, respectively. The most prevalent late tachyarrhythmia was atrial flutter (50%), followed by supraventricular tachycardia (25%) and ventricular tachycardia (25%). Direct current cardioversion was required in 12 patients, and 7 patients underwent electrophysiological study. Freedom from Fontan circulatory failure after onset of tachyarrhythmia at 10 and 15 years was 78% and 49%, respectively. Freedom from occurrence of decreased ventricular systolic function after the onset of tachyarrhythmia at 5 years was 85%. Independent factors associated with late tachyarrhythmia were dominant right ventricle (hazard ratio, 2.52, p = 0.02) and weight at total cavopulmonary connection (hazard ratio, 1.03 per kilogram; p = 0.04). Type of total cavopulmonary connection at total cavopulmonary connection was not identified as risk. CONCLUSIONS: In our large cohort of 620 patients following total cavopulmonary connection, the incidence of late tachyarrhythmia was low. Patients with dominant right ventricle and late total cavopulmonary connection were at increased risk for late tachyarrhythmia following total cavopulmonary connection.

When Do Smartwatch Heart Rate Concerns in Children Indicate Arrhythmia?

OBJECTIVE: To determine the incidence and predictors of true arrhythmia in pediatric patients presenting with concerns about smartwatch cardiac data. STUDY DESIGN: Single-center, retrospective cohort study of children aged 10-18 years who had presented to a pediatric cardiology clinic between January 2018 and December 2021 with concerns related to smartwatch cardiac data. The primary study outcome was diagnosis of arrhythmia based on clinical evaluation or documentation of arrhythmia by clinical testing. RESULTS: There were 126 patients (mean age 15.6 ± 2.4 years) who presented with a smartwatch-based rhythm concern, with tachycardia in 89%. In all, 19 of 126 (15%) patients were diagnosed with true arrhythmia. The odds of a true arrhythmia diagnosis with symptoms vs no symptoms were 3.2 (95% CI 0.7-14.5), and with heart rate (HR) ≥190 beats/min vs HR <190 beats/min, it was 14.3 (95% CI 3.8-52.8). The positive predictive value of HR ≥190 beats/min and symptoms together to predict arrhythmia was only 39% (95% CI 28-52). The negative predictive value for arrhythmia having neither symptoms nor HR >190 was 95% (95% CI 75-99). CONCLUSION: The likelihood of a true arrhythmia in pediatric patients presenting with a smartwatch-based HR concern was low. Rarely, smartwatch electrograms or trend data were sufficient for arrhythmia diagnosis.

Initial heart rate score predicts new-onset atrial tachyarrhythmias in pacemaker patients.

AIMS: Heart rate score (HRSc), the per cent of atrial paced and sensed event in the largest 10 b.p.m. rate histogram bin of a pacemaker, predicts survival in patients with cardiac devices. No correlation between HRSc and development of atrial fibrillation (AF) has been reported. In this study, we evaluated the relationship between pacemaker post-implantation HRSc and the incidence of newly developed atrial tachyarrhythmias (ATAs). METHODS AND RESULTS: Patients with dual-chamber pacemakers, implanted 2013-17, with the LATITUDE remote monitoring data with ≥600 000 beats of histogram data collected at baseline were included (N = 34 543). Heart rate score was determined from the initial 3-month post-implantation histogram data. Patients were excluded if they had ATAs, defined as atrial high-rate episodes >5 min or >1% of right atrial beats >170 b.p.m. during the initial 3 months post-implantation. New ATAs, after the baseline period, were defined by each of the following: >1, >10, or >25% of atrial beats >170 b.p.m. or atrial tachycardia response (ATR) events >24 h. Patients were followed a median of 2.8 (1.0-4.0) years. The incidence of ATAs increased in proportion to HRSc (log-rank P-value <0.001), and the initial HRSc ≥70% was associated with increased ATAs by all definitions. Patients with initial HRSc ≥70% were older, had a higher percentage of right atrium pacing (%RA pacing), had a lower percentage of right ventricular pacing (%RV pacing), and were more likely programmed with rate-response vs. subjects with HRSc <70%. Initial HRSc (hazard ratio: 1.07, 95% confidence interval: 1.05-1.09; P < 0.0001) independently predicted ATAs after adjusting for age, gender, %RV pacing, and rate-response programming. The %RA pacing and initial HRSc were correlated. CONCLUSION: Heart rate score independently predicts any subsequent duration of ATAs in pacemaker patients.

Progression from paroxysmal to persistent atrial fibrillation in pacemaker patients with tachycardia-bradycardia syndrome: a multicenter study.

Progression from paroxysmal to persistent atrial fibrillation (AF) is occasionally encountered in patients with previous pacemaker implantation (PMI) for the treatment of tachycardia-bradycardia syndrome (TBS). We aimed to determine the rate of its incidence occurring within the early years after PMI and the predictors. We studied TBS patients who received PMI at 5 core cardiovascular centers. The end point was a conversion from paroxysmal to persistent AF. We extracted 342 TBS patients out of 2579 undergoing PMI. During 5 ± 3.1 years of follow-up, 114 (33.3%) reached the end point. The time to the end point was 2.9 ± 2.7 years. The event rates within a year and 3 years after the PMI were 8.8% and 19.6%, respectively. In the multivariate hazard analyses, hypertension (hazard ratio [HR] 3.2, P = 0.03) and congestive heart failure (HR 2.1, P = 0.04) were found to be independent predictors of the end point occurring within a year after the PMI. Congestive heart failure (HR 1.82, P = 0.04), left atrial diameter of ≥ 40 mm (HR 4.55, P < 0.001), and the use of antiarrhythmic agents (HR 0.58, P = 0.04) were independently associated with the 3-year end point. Prediction models including combinations of those 4 parameters for the 1- and 3-year incidence both exhibited a modest risk discrimination (both c-statistics 0.71). In conclusion, early progression from paroxysmal to persistent AF was less frequent than expected in the TBS patients with PMI. Factors related to atrial remodeling and no use of antiarrhythmic drugs may facilitate the progression.

Effectiveness of intraoperative use of dexmedetomidine in reducing the incidence of tachyarrhythmia after congenital cardiac surgery in neonates and infants: a doubly robust method estimation analysis.

OBJECTIVES: The antiarrhythmic effects of dexmedetomidine (DEX) have been suggested, but there are controversial reports on the effectiveness of intraoperative use of DEX to reduce the incidence of postoperative tachyarrhythmia (POT). METHODS: From a local European Congenital Heart Surgery Association database, we included patients operated for congenital heart diseases under cardiopulmonary bypass within a 5-year period (2017-2021), during which intraoperative use of high dose of DEX (1-1.4 µg/kg/h) was implemented. A doubly robust matching estimation of the causal effect of DEX on the incidence of POT was conducted. We combined a multimodal estimation model in patients not exposed to DEX (disease risk score) as well as a regression analysis in a matched cohort for patients exposured to DEX. RESULTS: From a cohort of 593 surgeries (514 patients) occurring during the study period, doubly matched analysis consisted of the analysis of 426 surgeries conducted under DEX or not (213 per group). The probability of developing POT in patients exposed to DEX was 6.6% (95% confidence interval 0.032-0.099) vs 14.5% (95% confidence interval 0.098-0.193) in the group of patients not exposed to DEX. The doubly robust matched estimation method showed a mean reduction of 8.8% (95% confidence interval -0.137 to -0.023) of POT when DEX is used for intraoperative anaesthesia. CONCLUSIONS: The use of high doses of DEX during anaesthesia for congenital heart surgery in neonates and infants is associated with a moderate but significant reduction of POT.

Predictors of tachycardia-induced cardiomyopathy in patients with first-time decompensation of chro-nic heart failure with reduced left ventricular ejection fraction of nonischemic etiology and persistent atrial tachyarrhythmia.

Aim    To identify possible predictors of tachycardia-induced cardiomyopathy (TICMP) in patients with newly developed decompensated chronic heart failure (CHF) of nonischemic origin with reduced left ventricular ejection fraction (LV EF) and with persistent atrial tachyarrhythmias. Material and methods    This study included 88 patients with newly developed decompensated CHF of nonischemic origin with reduced LV EF and persistent atrial tachyarrhythmias. Resting 12-lead electrocardiography (EGC) and transthoracic echocardiography (EchoCG) were performed upon admission and following the electrical impulse therapy for all patients. Also, 24-h ECG monitoring was performed to confirm sinus rhythm stability. After recovery of sinus rhythm, outpatient monitoring was performed for three months, including repeated EchoCG to evaluate the dynamics of heart chamber dimensions and LV EF. Results    The patients were divided into two groups based on the increase in LV EF: 68 responders (TICMP patients with a LV EF increase by >10%) and 20 non-responders (patients with an increase in LV EF by <10% during 3 months following the sinus rhythm recovery). According to results of the baseline EchoCG, LV EF did not significantly differ in the two subgroups (TICMP, 40±8.3 %, 18-50 % and non-responders, 38.55±7.9 %, 24-50 %); moreover, the incidence of cases with LV EF <30% did not differ either (9 patients TICMP and 2 non-responders, р=1.0). TICMP patients compared to non-responders, had significantly smaller left atrial dimensions (4.53±1.14 (2-7) cm and 5.68±1.41 (4-8) cm, р=0.034; 80.8±28.9 (27-215) ml and 117.8±41.3 (46-230) ml, р=0.03, respectively) and left ventricular end-systolic volume (ESV) (67.7±33.1 (29-140) ml and 104.5±44.7 (26-172) ml, р=0.02, respectively). The effect of major EchoCG parameters on the probability of TICMP development was assessed by one-factor and multifactor regression analyses with adjustments for age and sex. The probability of TICMP increased with the following baseline EchoCG parameters: end-diastolic volume (EDV) <174 ml [odd ratio (OR), 0.115, 95 % confidence interval (CI): 0.035-0.371], ESV <127 ml [OR, 0.034, 95 % CI: 0.007-0.181], left atrial volume <96 ml [OR, 0.08 , 95 % CI: 0.023-0.274], right ventricular dimension <4 cm [OR, 0.042 , 95 % CI: 0.005-0.389].Conclusion    Among patients with newly developed decompensation of CHF with reduced LV EF of non-ischemic origin and persistent atrial arrhythmias, TICMP was detected in 72 % of patients. The probability of TICMP did not depend on baseline EF and duration of arrhythmias, but increased with the following baseline EchoCG parameters: EDV< 174 ml, ESV< 127 ml, left atrial volume <96 ml, right ventricular dimension <4 cm. The multifactorial analysis showed that a right atrial volume <96 ml is an independent predictor for the development of TICMP.

Amiodarona: fortalezas y debilidades / Amiodarone strengths and weaknesses

Prescritos en la práctica clínica por su eficacia. En su inicio se utilizó para tratar la angina de pecho. hoy día es usado para el tratamiento de cualquier forma de taquicardia. Objetivo: Reconocer la prescripción de la Amiodarona y sus efectos adversos. Métodos: Se realizó una revisión descriptiva en las bases de datos de Lilacs donde se encontraron 18 artículos y en PubMed/Medline (Mesh) 206 artículos, de los cuales se le aplicaron los criterios de inclusión a 51 artículos. Conclusiones: La amiodarona es uno de los antiarrítmicos más utilizados para el tratamiento de las arritmias, su variedad de efectos adversos y toxicidad es conocida, por tanto, los pacientes en tratamiento ameritan un minucioso monitoreo(AU)

Introduction: Amiodarone is one of the most prescribed antiarrhythmic drugs in clinical practice due to its efficacy. Initially it was used to treat angina pectoris, however, today it is used to treat any form of tachycardia. Objective: To identify the prescription of amiodarone and its adverse effects. Methods: A descriptive review was carried out in Lilacs databases where 18 articles were found and in PubMed/Medline (Mesh) 206 articles were retrieved. The inclusion criteria were applied to 51 articles. Conclusions: Amiodarone is one of the most widely used antiarrhythmic drugs for the treatment of arrhythmias, its variety of adverse effects and toxicity is known, therefore, patients undergoing treatment justify careful monitoring(AU)

Monotherapy with mirabegron had a better tolerance than the anticholinergic agents on overactive bladder: A systematic review and meta-analysis.

BACKGROUND: We conducted this meta-analysis to explore the tolerance of monotherapy with mirabegron (50 mg) on an overactive bladder, compared with a common dosage of anticholinergic agents. MATERIALS AND METHODS: A comprehensive search for all randomized controlled trials that evaluated the safety of mirabegron and anticholinergic agents on overactive bladder was performed, and we searched the Cochrane Central Register of Controlled trials databases, Pubmed, Embase, and relevant trials from 2013.02 to 2019.10. RESULTS: Eight studies included 5500 patients with treatment of monotherapy on overactive bladder were identified. The total number of treatment-emergent adverse events had no significantly difference between two monotherapies (RR = 0.88 95%CI: 0.76-1.01; P = .08); however, patients would have a better tolerance with mirabegron (50 mg) in adverse events of dry mouth (RR = 0.42; 95%CI: 0.33-0.53; P < .01) and tachycardia (RR = 0.52; 95%CI: 0.29-0.94; P = .03); and there were no significant differences between two groups in hypertension (RR = 1.02; 95%CI: 0.80-1.30; P = .90), constipation (RR = 0.91; 95%CI: 0.65-1.26; P = 0.57), blurred vision (RR = 1.03; 95%CI: 0.60-1.77; P = 0.92), and urinary tract infection (RR = 0.90; 95%CI: 0.70-1.16; P = .41). CONCLUSIONS: Treatment-emergent adverse events in patients with overactive bladder who underwent monotherapy of mirabegron (50 mg) or the anticholinergic agents had no significant differences, but mirabegron has a better tolerance in the aspect of dry mouth and tachycardia.

Post COVID-19 Syndrome ("Long COVID") and Diabetes: Challenges in Diagnosis and Management.

BACKGROUND AND AIMS: Post Covid-19 syndrome (PCS) is a major cause of morbidity. In this article we intend to review the association and consequences of PCS and diabetes. METHODS: We reviewed all studies on "Long Covid", "Post COVID-19 Syndrome" and diabetes in PubMed and Google Scholar. RESULTS: The symptoms of PCS can be due to organ dysfunction, effects of hospitalisation and drugs, or unrelated to these. Type 2 diabetes mellitus has a bidirectional relationship with COVID-19. Presence of diabetes also influences PCS via various pathophysiological mechanisms. COVID-19 can add to or exacerbate tachycardia, sarcopenia (and muscle fatigue), and microvascular dysfunction (and organ damage) in patients with diabetes. CONCLUSION: PCS in patients with diabetes could be detrimental in multiple ways. Strict control of diabetes and other comorbidities, supervised rehabilitation and physical exercise, and optimal nutrition could help in reducing and managing PCS.

A Brazilian Portuguese translation, cultural adaptation and validation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) health-related quality of life (HRQOL) scale.

INTRODUCTION: The health-related quality of life (HRQOL) of patients with tachyarrhythmia can be negatively influenced by the clinical manifestations. The evaluation of HRQOL with validated instruments can provide valuable information that will contribute to clinical decision-making and treatment. In Brazil, however, there is no available scale that evaluates HRQOL in different types of arrhythmia. The purpose of this study was to adapt the Arrhythmia-Specific Questionnaire in Tachycardia and Arrhythmia-HRQOL scale (ASTA-HRQOL scale) to the Brazilian culture, and to assess the psychometric properties of the adapted questionnaire. METHODS: The study used a methodological process of cultural adaptation based on international literature guidelines. The analyses were performed with 172 participants, 32 for cultural adaptation and 140 for psychometric validation. Calculation included analysis of reliability by Cronbach's α coefficient, construct validity with convergent validity using the WHOQOL-BREF questionnaire and by the Spearman correlation coefficient, Average Variance Extracted, and assessment of confirmatory factor analysis. RESULTS: The translation and adaptation processes showed a satisfactory degree of comprehension and applicability (93% reported them to be easy to understand). Confirmatory factor analysis indicated exclusion of one item from the mental scale, but after qualitative analysis the item was retained. The items presented adequate internal consistency (Cronbach's alpha coefficient = 0.88), and an inverse correlation of moderate magnitude with the physical domain (rho = -0.63) and with the mental domain (rho = -0.58) of the WHOQOL-BREF. CONCLUSIONS: The Brazilian Portuguese version of the ASTA-HRQOL scale, the ASTA-Br-HRQOL scale, can be a valuable tool for use in clinical practice and research.

Coffee Consumption and Incident Tachyarrhythmias: Reported Behavior, Mendelian Randomization, and Their Interactions.

Importance: The notion that caffeine increases the risk of cardiac arrhythmias is common. However, evidence that the consumption of caffeinated products increases the risk of arrhythmias remains poorly substantiated. Objective: To assess the association between consumption of common caffeinated products and the risk of arrhythmias. Design, Setting, and Participants: This prospective cohort study analyzed longitudinal data from the UK Biobank between January 1, 2006, and December 31, 2018. After exclusion criteria were applied, 386 258 individuals were available for analyses. Exposures: Daily coffee intake and genetic polymorphisms that affect caffeine metabolism. Main Outcomes and Measures: Any cardiac arrhythmia, including atrial fibrillation or flutter, supraventricular tachycardia, ventricular tachycardia, premature atrial complexes, and premature ventricular complexes. Results: A total of 386 258 individuals (mean [SD] age, 56 [8] years; 52.3% female) were assessed. During a mean (SD) follow-up of 4.5 (3.1) years, 16 979 participants developed an incident arrhythmia. After adjustment for demographic characteristics, comorbid conditions, and lifestyle habits, each additional cup of habitual coffee consumed was associated with a 3% lower risk of incident arrhythmia (hazard ratio [HR], 0.97; 95% CI, 0.96-0.98; P < .001). In analyses of each arrhythmia alone, statistically significant associations exhibiting a similar magnitude were observed for atrial fibrillation and/or flutter (HR, 0.97; 95% CI, 0.96-0.98; P < .001) and supraventricular tachycardia (HR, 0.96; 95% CI, 0.94-0.99; P = .002). Two distinct interaction analyses, one using a caffeine metabolism-related polygenic score of 7 genetic polymorphisms and another restricted to CYP1A2 rs762551 alone, did not reveal any evidence of effect modification. A mendelian randomization study that used these same genetic variants revealed no significant association between underlying propensities to differing caffeine metabolism and the risk of incident arrhythmia. Conclusions and Relevance: In this prospective cohort study, greater amounts of habitual coffee consumption were associated with a lower risk of arrhythmia, with no evidence that genetically mediated caffeine metabolism affected that association. Mendelian randomization failed to provide evidence that caffeine consumption was associated with arrhythmias.

Epidemiology of cannabidiol related cases reported in the National Poison Data System - 2019-2020.

INTRODUCTION: Cannabidiol (CBD) has become a popular supplement in consumer products in recent years, resulting in part from normalization of the cultivation of low THC cannabis in 2018. However, the actual content of CBD-labeled products is frequently uncertain, as oversight of such products is minimal. To date, there is little pragmatic knowledge regarding exposures to products labeled as containing CBD. METHODS: Cases reported to Poison Control Centers from April 1, 2019 and March 31, 2020, the first year in which CBD was identified uniquely as a substance in the National Poison Data System, were analyzed for demographic, temporal, and clinical trends. RESULTS: Poison Control Centers handled 1581 cases exposures to CBD-containing products between April 1, 2019 and March 31, 2020. There was a significant trend of over 5 additional cases related to this substance per month (linear regression coefficient = 5.2, 95% CI: 1.52-8.98). Patients under age 13 years made up 44.0% of reported exposures. Mild CNS depression (10.3%), tachycardia (5.7%), dizziness/vertigo (5.3%), vomiting (4.9%), nausea (4.5%), and agitation (4.4%) were the most frequently reported symptoms. 13% of cases were coded as having "moderate" or "severe" medical outcomes. There were no fatalities. CONCLUSIONS: Cases reported to Poison Control Centers regarding exposures to CBD-labeled products have been increasing, representing an emerging trend of interest to Poison Control Center professionals, clinicians, and public health officials. Further monitoring of this trend is recommended.

Predictors of New-Onset Atrial Tachyarrhythmias After Transcatheter Atrial Septal Defect Closure in Adults.

BACKGROUND: New-onset atrial tachyarrhythmia (ATA) often develops after atrial septal defect (ASD) closure. Its development raises some potential concerns such as stroke and bleeding complications caused by anticoagulant therapy and limited access to the left atrium for catheter ablation. Although it is essential to identify the risk factors of new-onset ATA, few studies have examined these factors. This study investigated unknown risk factors for the development of new-onset ATA after transcatheter ASD closure in patients without a history of ATA. METHODS: A total of 238 patients without a history of ATA, aged ≥18 years and who underwent transcatheter ASD closure at the current hospital were reviewed. Patient characteristics were compared between the groups with and without new-onset ATA. The factors associated with new-onset ATA were examined using univariate and multivariable analyses. RESULTS: Thirteen (13) (5.5%) patients experienced ATA during follow-up (mean, 21±14 months). Compared with patients without new-onset ATA, patients with new-onset ATA were older (48±18 vs 66±11 years; p<0.001) and had high brain natriuretic peptide (BNP) levels (36±36 vs 177±306 pg/mL; p<0.001). On multivariable analysis, BNP ≥40 pg/mL before ASD closure was associated with new-onset ATA after adjusting for age (OR, 4.91; 95% CI, 1.22-19.8; p=0.025). CONCLUSION: Patients with BNP levels >40 pg/mL before transcatheter ASD closure may have a higher risk of developing new-onset ATA.

Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients.

BACKGROUND: The major concern regarding the use of low-dose oral minoxidil (LDOM) for the treatment of hair loss is the potential risk of systemic adverse effects. OBJECTIVE: To describe the safety of LDOM for the treatment of hair loss in a large cohort of patients. METHODS: Retrospective multicenter study of patients treated with LDOM for at least 3 months for any type of alopecia. RESULTS: A total of 1404 patients (943 women [67.2%] and 461 men [32.8%]) with a mean age of 43 years (range 8-86) were included. The dose of LDOM was titrated in 1065 patients, allowing the analysis of 2469 different cases. The most frequent adverse effect was hypertrichosis (15.1%), which led to treatment withdrawal in 14 patients (0.5%). Systemic adverse effects included lightheadedness (1.7%), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%), leading to drug discontinuation in 29 patients (1.2%). No life-threatening adverse effects were observed. LIMITATIONS: Retrospective design and lack of a control group. CONCLUSION: LDOM has a good safety profile as a treatment for hair loss. Systemic adverse effects were infrequent and only 1.7% of patients discontinued treatment owing to adverse effects.

Detection of Tachyarrhythmias in a Large Cohort of Infants Using Direct-to-Consumer Heart Rate Monitoring.

OBJECTIVE: Current estimates of the incidence of tachyarrhythmias in infants rely on clinical documentation and may not reflect the true rate in the general population. Our aim was to describe the epidemiology of tachyarrhythmia detected in a large cohort of infants using direct-to-consumer heart rate (HR) monitoring. STUDY DESIGN: Data were collected from Owlet Smart Sock devices used in infants in the US with birthdates between February 2017 and February 2019. We queried the HR data for episodes of tachyarrhythmia (HR of ≥240 bpm for >60 seconds). RESULTS: The study included 100 949 infants (50.8% male) monitored for more than 200 million total hours. We identified 5070 episodes of tachyarrhythmia in 2508 infants. The cumulative incidence of tachyarrhythmia in our cohort was 2.5% over the first year of life. The median age at the time of the first episode of tachyarrhythmia was 36 days (range, 1-358 days). Tachyarrhythmia was more common in infants with congenital heart disease (4.0% vs 2.4%; P = .015) and in females (2.7% vs 2.0%; P < .001). The median length of an episode was 7.3 minutes (range, 60 seconds to 5.4 hours) and the probability of an episode lasting longer than 45 minutes was 16.8% (95% CI, 15.4%-18.3%). CONCLUSIONS: We found the cumulative incidence of tachyarrhythmia among infants using direct-to-consumer HR monitors to be higher than previously reported in studies relying on clinical diagnosis. This finding may represent previously undetected subclinical disease in young infants, the significance of which remains uncertain. Clinicians should be prepared to discuss these events with parents.

Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study.

OBJECTIVES: To describe the prevalence, nature and risk factors for the main clinical sequelae in coronavirus disease 2019 (COVID-19) survivors who have been discharged from the hospital for more than 3 months. METHODS: This longitudinal study was based on a telephone follow-up survey of COVID-19 patients hospitalized and discharged from Renmin Hospital of Wuhan University, Wuhan, China before 1 March 2020. Demographic and clinical characteristics and self-reported clinical sequelae of the survivors were described and analysed. A cohort of volunteers who were free of COVID-19 and lived in the urban area of Wuhan during the outbreak were also selected as the comparison group. RESULTS: Among 538 survivors (293, 54.5% female), the median (interquartile range) age was 52.0 (41.0-62.0) years, and the time from discharge from hospital to first follow-up was 97.0 (95.0-102.0) days. Clinical sequelae were common, including general symptoms (n = 267, 49.6%), respiratory symptoms (n = 210, 39%), cardiovascular-related symptoms (n = 70, 13%), psychosocial symptoms (n = 122, 22.7%) and alopecia (n = 154, 28.6%). We found that physical decline/fatigue (p < 0.01), postactivity polypnoea (p= 0.04) and alopecia (p < 0.01) were more common in female than in male subjects. Dyspnoea during hospitalization was associated with subsequent physical decline/fatigue, postactivity polypnoea and resting heart rate increases but not specifically with alopecia. A history of asthma during hospitalization was associated with subsequent postactivity polypnoea sequela. A history of pulse ≥90 bpm during hospitalization was associated with resting heart rate increase in convalescence. The duration of virus shedding after COVID-19 onset and hospital length of stay were longer in survivors with physical decline/fatigue or postactivity polypnoea than in those without. CONCLUSIONS: Clinical sequelae during early COVID-19 convalescence were common; some of these sequelae might be related to gender, age and clinical characteristics during hospitalization.

Intrapartum zigzag pattern of fetal heart rate is an early sign of fetal hypoxia: A large obstetric retrospective cohort study.

INTRODUCTION: The aim of the present study was to identify possible associations of fetal heart rate (FHR) patterns during the last 2 hours of labor with fetal asphyxia expressed by umbilical artery acidemia at birth and with neonatal complications in a large obstetric cohort. MATERIAL AND METHODS: Cardiotocographic recordings from 4988 singleton term childbirths over 1 year were evaluated retrospectively and blinded to the pregnancy and neonatal outcomes in a university teaching hospital in Helsinki, Finland. Umbilical artery pH, base excess and pO2 , low Apgar scores at 5 minutes, need for intubation and resuscitation, early neonatal hypoglycemia, and neonatal encephalopathy were used as outcome variables. According to the severity of the neonatal complications at birth, the cohort was divided into three groups: no complications (Group 1), moderate complications (Group 2) and severe complications (Group 3). RESULTS: Of the 4988 deliveries, the ZigZag pattern (FHR baseline amplitude changes of >25 bpm with a duration of 2-30 minutes) occurred in 11.7%, late decelerations in 41.0%, bradycardia episodes in 52.9%, reduced variability in 36.7%, tachycardia episodes in 13.9% and uterine tachysystole in 4.6%. No case of saltatory pattern (baseline amplitude changes of >25 bpm with a duration of >30 minutes) was observed. The presence of the ZigZag pattern or late decelerations, or both, was associated with cord blood acidemia (odds ratio [OR] 3.3, 95% confidence interval [CI] 2.3-4.7) and severe neonatal complications (Group 3) (OR 3.3, 95% CI 2.4-4.9). In contrast, no significant associations existed between the other FHR patterns and severe neonatal complications. ZigZag pattern preceded late decelerations in 88.7% of the cases. A normal FHR preceded the ZigZag pattern in 90.4% of the cases, whereas after ZigZag episodes, a normal FHR pattern was observed in only 0.9%. CONCLUSIONS: ZigZag pattern and late decelerations during the last 2 hours of labor are significantly associated with cord blood acidemia at birth and neonatal complications. The ZigZag pattern precedes late decelerations, and the fact that normal FHR pattern precedes the ZigZag pattern in the majority of the cases suggests that the ZigZag pattern is an early sign of fetal hypoxia, which emphasizes its clinical importance.

U-Shaped Association Between Intraoperative Net Fluid Balance and Risk of Postoperative Recurrent Atrial Tachyarrhythmia Among Patients Undergoing the Cryo-Maze Procedure: An Observational Study.

OBJECTIVE: The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. DESIGN: An observational cohort study. SETTING: A tertiary care hospital from April 2007 to May 2019. PARTICIPANTS: Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. INTERVENTIONS: The Cryo-Maze procedure in conjunction with other cardiac surgeries. MEASUREMENTS AND MAIN RESULTS: The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, -215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (-1.52) when net fluid balance was 1,557 mL. CONCLUSIONS: There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.