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1.
J AAPOS ; 23(4): 193-199, 2019 08.
Article in English | MEDLINE | ID: mdl-30981895

ABSTRACT

An increasing number of surgical strabismus patients are taking oral anticoagulant and antiplatelet agents, with more diverse mechanisms of action than those used in the past. The decision as to whether to continue these drugs throughout the perioperative period is difficult and must be based on the balance between hemorrhagic and thrombotic risk. To help guide strabismus surgeons with clinical management in these cases, we review potential hemorrhagic complications of strabismus surgery and examine the use of anticoagulant and antiplatelet drugs during the perioperative period. Surgical strategies that might help minimize intraoperative hemorrhage in patients on anticoagulant therapy are also discussed.


Subject(s)
Anticoagulants/adverse effects , Eye Hemorrhage/chemically induced , Ophthalmologic Surgical Procedures , Risk Assessment/methods , Strabismus/surgery , Decision Making , Eye Hemorrhage/epidemiology , Global Health , Humans , Incidence
2.
Int J Cardiol ; 164(1): 58-63, 2013 Mar 20.
Article in English | MEDLINE | ID: mdl-21777987

ABSTRACT

BACKGROUND: Endomycocardial biopsies have demonstrated that subclinical myocarditis is a universal feature of acute Kawasaki disease (KD). METHODS: We investigated biochemical evidence of myocardial strain, oxidative stress, and cardiomyocyte injury in 55 acute KD subjects (30 with paired convalescent samples), 54 febrile control (FC), and 50 healthy control (HC) children by measuring concentrations of cardiovascular biomarkers. RESULTS: Levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and soluble ST2 (sST2) were elevated in acute vs. convalescent KD, FC, and HC (p≤0.002), while γ-glutamyl transferase and alanine amino transferase as measures of oxidative stress were increased in acute vs. FC (p≤0.0002). Cardiac troponin I (cTnI) levels, using a highly sensitive assay, were elevated in 30% and 40% of paired acute and convalescent KD subjects, respectively, and normalized within two years of disease onset. NT-proBNP and sST2 negatively correlated with deceleration time, but only NT-proBNP correlated with MV E:A ratio and internal diameter of the coronary arteries (RCA/LAD Zworst). CONCLUSIONS: NT-proBNP and sST2 were elevated in acute KD subjects and correlated with impaired myocardial relaxation. These findings, combined with elevated levels of cTnI, suggest that both cardiomyocyte stress and cell death are associated with myocardial inflammation in acute KD.


Subject(s)
Mucocutaneous Lymph Node Syndrome/blood , Acute Disease , Adolescent , Biomarkers/blood , Child , Child, Preschool , Female , Humans , Infant , Male , Mucocutaneous Lymph Node Syndrome/complications , Myocarditis/blood , Myocarditis/etiology , Natriuretic Peptide, Brain/blood , Peptide Fragments/blood , Troponin I/blood
3.
Pediatr Infect Dis J ; 31(9): 924-6, 2012 Sep.
Article in English | MEDLINE | ID: mdl-22673140

ABSTRACT

BACKGROUND: In the absence of a specific test, the diagnosis of clinically incomplete Kawasaki disease (KD) can be challenging. The 2004 American Heart Association guidelines state that the diagnosis of KD is supported by the presence of coronary artery dilation documented by echocardiography. However, the specificity of coronary artery dilation and its prevalence in children with other acute illnesses associated with fever has not been studied. METHODS: A 2-center, prospective study compared the internal diameters and Z-scores (standard deviation [SD] units from the mean internal diameter normalized for body surface area) of the proximal left anterior descending and right coronary arteries measured by echocardiography in febrile children (FC) and children with KD. RESULTS: The median Z-score (interquartile range) of the left anterior descending coronary artery was -0.05 (-0.86, 0.62) and 1.06 (0.36, 2.06) SD units for the 45 FC and the 145 KD patients, respectively (P < 0.0001). For the right coronary artery, the median Z-score was 0.21 (-0.20, 0.87) and 1.04 (0.31, 1.85) SD units for the FC and KD patients, respectively (P < 0.0001). There was no correlation between body temperature at the time of echocardiography and coronary artery Z-score. No febrile child had a coronary artery Z-score ≥ 2.5 SD units. CONCLUSIONS: Z-scores ≥ 2.5 SD units were not observed in our cohort of FC. Therefore, echocardiographic evidence of coronary artery dilation can be used to support the diagnosis of KD.


Subject(s)
Coronary Aneurysm/pathology , Coronary Vessels/pathology , Fever/pathology , Mucocutaneous Lymph Node Syndrome/pathology , Child , Child, Preschool , Coronary Aneurysm/complications , Coronary Aneurysm/diagnostic imaging , Coronary Vessels/diagnostic imaging , Echocardiography , Female , Fever/complications , Humans , Infant , Male , Mucocutaneous Lymph Node Syndrome/complications , Mucocutaneous Lymph Node Syndrome/surgery , Prospective Studies , Statistics, Nonparametric
4.
Circ Cardiovasc Genet ; 4(1): 16-25, 2011 Feb.
Article in English | MEDLINE | ID: mdl-21127203

ABSTRACT

BACKGROUND: Transforming growth factor (TGF)-ß is a multifunctional peptide that is important in T-cell activation and cardiovascular remodeling, both of which are important features of Kawasaki disease (KD). We postulated that variation in TGF-ß signaling might be important in KD susceptibility and disease outcome. METHODS AND RESULTS: We investigated genetic variation in 15 genes belonging to the TGF-ß pathway in a total of 771 KD subjects of mainly European descent from the United States, the United Kingdom, Australia, and the Netherlands. We analyzed transcript abundance patterns using microarray and reverse transcriptase-polymerase chain reaction for these same genes, and measured TGF-ß2 protein levels in plasma. Genetic variants in TGFB2, TGFBR2, and SMAD3 and their haplotypes were consistently and reproducibly associated with KD susceptibility, coronary artery aneurysm formation, aortic root dilatation, and intravenous immunoglobulin treatment response in different cohorts. A SMAD3 haplotype associated with KD susceptibility replicated in 2 independent cohorts and an intronic single nucleotide polymorphism in a separate haplotype block was also strongly associated (A/G, rs4776338) (P=0.000022; odds ratio, 1.50; 95% confidence interval, 1.25 to 1.81). Pathway analysis using all 15 genes further confirmed the importance of the TGF-ß pathway in KD pathogenesis. Whole-blood transcript abundance for these genes and TGF-ß2 plasma protein levels changed dynamically over the course of the illness. CONCLUSIONS: These studies suggest that genetic variation in the TGF-ß pathway influences KD susceptibility, disease outcome, and response to therapy, and that aortic root and coronary artery Z scores can be used for phenotype/genotype analyses. Analysis of transcript abundance and protein levels further support the importance of this pathway in KD pathogenesis.


Subject(s)
Mucocutaneous Lymph Node Syndrome/genetics , Signal Transduction/genetics , Transforming Growth Factor beta/genetics , Aorta/pathology , Australia , Cohort Studies , Coronary Vessels/metabolism , Coronary Vessels/pathology , Genetic Predisposition to Disease , Haplotypes/genetics , Humans , Immunoglobulins, Intravenous/therapeutic use , Linkage Disequilibrium/genetics , Mucocutaneous Lymph Node Syndrome/blood , Mucocutaneous Lymph Node Syndrome/drug therapy , Phenotype , Polymorphism, Single Nucleotide/genetics , Protein Serine-Threonine Kinases/genetics , RNA, Messenger/blood , RNA, Messenger/genetics , Receptor, Transforming Growth Factor-beta Type II , Receptors, Transforming Growth Factor beta/genetics , Smad3 Protein/genetics , Transforming Growth Factor beta2/genetics , United Kingdom , United States
5.
Pediatrics ; 125(2): e234-41, 2010 Feb.
Article in English | MEDLINE | ID: mdl-20100771

ABSTRACT

OBJECTIVE: The 2004 American Heart Association (AHA) statement included a clinical case definition and an algorithm for diagnosing and treating suspected incomplete Kawasaki disease (KD). We explored the performance of these recommendations in a multicenter series of US patients with KD with coronary artery aneurysms (CAAs). METHODS: We reviewed retrospectively records of patients with KD with CAAs at 4 US centers from 1981 to 2006. CAAs were defined on the basis of z scores of >3 or Japanese Ministry of Health and Welfare criteria. Our primary outcome was the proportion of patients presenting at illness day < or =21 who would have received intravenous immunoglobulin (IVIG) treatment by following the AHA guidelines at the time of their initial presentation to the clinical center. RESULTS: Of 195 patients who met entry criteria, 137 (70%) met the case definition and would have received IVIG treatment at presentation. Fifty-three patients (27%) had suspected incomplete KD and were eligible for algorithm application; all would have received IVIG treatment at presentation. Of the remaining 5 patients, 3 were excluded from the algorithm because of fever for <5 days at presentation and 2 because of <2 clinical criteria at >6 months of age. Two of these 5 patients would have entered the algorithm and received IVIG treatment after follow-up monitoring. Overall, application of the AHA algorithm would have referred > or =190 patients (97%) for IVIG treatment. CONCLUSIONS: Application of the 2004 AHA recommendations, compared with the classic criteria alone, improves the rate of IVIG treatment for patients with KD who develop CAAs. Future multicenter prospective studies are needed to assess the performance characteristics of the AHA algorithm in febrile children with incomplete criterion findings and to refine the algorithm further.


Subject(s)
Immunoglobulins, Intravenous/therapeutic use , Immunologic Factors/therapeutic use , Mucocutaneous Lymph Node Syndrome/diagnosis , Mucocutaneous Lymph Node Syndrome/therapy , Adolescent , Algorithms , Child , Child, Preschool , Coronary Aneurysm/etiology , Female , Humans , Infant , Infant, Newborn , Male , Mucocutaneous Lymph Node Syndrome/complications , Practice Guidelines as Topic , Young Adult
6.
Pediatrics ; 123(5): e783-9, 2009 May.
Article in English | MEDLINE | ID: mdl-19403470

ABSTRACT

OBJECTIVE: We sought to define the characteristics that distinguish Kawasaki disease shock syndrome from hemodynamically normal Kawasaki disease. METHODS: We collected data prospectively for all patients with Kawasaki disease who were treated at a single institution during a 4-year period. We defined Kawasaki disease shock syndrome on the basis of systolic hypotension for age, a sustained decrease in systolic blood pressure from baseline of > or =20%, or clinical signs of poor perfusion. We compared clinical and laboratory features, coronary artery measurements, and responses to therapy and analyzed indices of ventricular systolic and diastolic function during acute and convalescent Kawasaki disease. RESULTS: Of 187 consecutive patients with Kawasaki disease, 13 (7%) met the definition for Kawasaki disease shock syndrome. All received fluid resuscitation, and 7 (54%) required vasoactive infusions. Compared with patients without shock, patients with Kawasaki disease shock syndrome were more often female and had larger proportions of bands, higher C-reactive protein concentrations, and lower hemoglobin concentrations and platelet counts. Evidence of consumptive coagulopathy was common in the Kawasaki disease shock syndrome group. Patients with Kawasaki disease shock syndrome more often had impaired left ventricular systolic function (ejection fraction of <54%: 4 of 13 patients [31%] vs 2 of 86 patients [4%]), mitral regurgitation (5 of 13 patients [39%] vs 2 of 83 patients [2%]), coronary artery abnormalities (8 of 13 patients [62%] vs 20 of 86 patients [23%]), and intravenous immunoglobulin resistance (6 of 13 patients [46%] vs 32 of 174 patients [18%]). Impairment of ventricular relaxation and compliance persisted among patients with Kawasaki disease shock syndrome after the resolution of other hemodynamic disturbances. CONCLUSIONS: Kawasaki disease shock syndrome is associated with more-severe laboratory markers of inflammation and greater risk of coronary artery abnormalities, mitral regurgitation, and prolonged myocardial dysfunction. These patients may be resistant to immunoglobulin therapy and require additional antiinflammatory treatment.


Subject(s)
Hypotension/etiology , Mucocutaneous Lymph Node Syndrome/complications , Child , Child, Preschool , Critical Care , Female , Humans , Infant , Male , Mucocutaneous Lymph Node Syndrome/diagnostic imaging , Mucocutaneous Lymph Node Syndrome/physiopathology , Prospective Studies , Treatment Outcome , Ultrasonography
7.
Catheter Cardiovasc Interv ; 73(2): 181-8, 2009 Feb 01.
Article in English | MEDLINE | ID: mdl-19156885

ABSTRACT

OBJECTIVES: To determine the short and intermediate term outcome following systemic venous stent placement in children with congenital heart disease. BACKGROUND: Patients with congenital heart disease are at risk of stenosis or occlusion of systemic veins following indwelling lines or catheterizations. Stent dilation may ameliorate symptoms and open the vessel for use during future procedures. We report our acute and intermediate results. METHODS: All patients with systemic venous stent placement in the iliofemoral veins, inferior or superior vena cava at our institution between 1998 and 2006 were included. Initial and the follow-up catheterization data were reviewed retrospectively. RESULTS: 70 stents were placed in 33 patients (36 vessels). Median age was 2.6 years (0.2-14.2) and weight 11.5 kg (3.8-78.7). 17/36 vessels (47%) were occluded requiring recanalization. Following stent delivery, the mean minimum vessel diameter increased from 3.1 +/- 3.2 to 7.2 +/- 3.0 mm (P < 0.001). There were no major complications. Seventeen patients and vessels had a total of 62 follow-up catheterizations, with median length of follow-up 4.1 years (0.7-9.3). During intermediate follow up, 7/17 vessels (41%) required additional intervention. Six patients had additional balloon dilation of existing stents, and one additional stent was placed. Vessels were further dilated to 8.4 +/- 3.5 mm at the last catheterization. CONCLUSION: Systemic venous stents are safe and effective in recanalizing stenosed or occluded vessels. At follow-up, reocclusion can occur, however, previously placed stents can be safely recanalized if necessary. Future studies will determine if stenting is indicated in a broader population.


Subject(s)
Catheterization/instrumentation , Femoral Vein , Heart Defects, Congenital/therapy , Iliac Vein , Peripheral Vascular Diseases/therapy , Stents , Vena Cava, Inferior , Vena Cava, Superior , Adolescent , Cardiac Catheterization/adverse effects , Catheterization, Peripheral/adverse effects , Catheters, Indwelling/adverse effects , Child , Child, Preschool , Constriction, Pathologic , Female , Femoral Vein/diagnostic imaging , Femoral Vein/physiopathology , Humans , Iliac Vein/diagnostic imaging , Iliac Vein/physiopathology , Infant , Male , Peripheral Vascular Diseases/diagnostic imaging , Peripheral Vascular Diseases/etiology , Phlebography , Recurrence , Retrospective Studies , Superior Vena Cava Syndrome/etiology , Superior Vena Cava Syndrome/therapy , Time Factors , Treatment Outcome , Vascular Patency , Vena Cava, Inferior/diagnostic imaging , Vena Cava, Inferior/physiopathology , Vena Cava, Superior/diagnostic imaging , Vena Cava, Superior/physiopathology , Venous Insufficiency/etiology , Venous Insufficiency/therapy , Venous Thrombosis/etiology , Venous Thrombosis/therapy
8.
Ann Thorac Surg ; 75(1): 147-51; discussion 151-2, 2003 Jan.
Article in English | MEDLINE | ID: mdl-12537208

ABSTRACT

BACKGROUND: Complex left ventricular outflow tract (LVOT) obstruction with normal aortic valve function requires aggressive resection in the subaortic region and preservation of the aortic valve. The modified Konno procedure allows generous exposure of the LVOT from the left ventricular apex to the inter leaflet trigones of the aortic valve. Widespread use of this procedure has been limited by concern over injury to the aortic valve, the conduction system, and possibility of residual ventricular septal defect (VSD). METHODS: Retrospective analysis of pertinent data for all patients undergoing the modified Konno procedure (1994 to 2001) at the University of Iowa were reviewed. RESULTS: The modified Konno procedure was used in 18 patients (age 1 to 31) for LVOT obstruction associated with diffuse narrowing of the LVOT (n = 7), a discrete fibrous ring (n = 7), or a fibrous ring associated with abnormal mitral attachments (n = 4). Eight patients had previously undergone LVOT resection. There were no perioperative deaths. Estimated LVOT peak gradients by echocardiogram were 70.4 +/- 24.2 mm Hg (preoperative) and 19.2 +/- 20.4 mm Hg (postoperative) at most recent followup (p < 0.001 vs preop). Aortic insufficiency was moderate in one patient (present preop) and mild or less in all other patients. There were no cases of permanent heart block. Small residual VSDs were present in five patients (28%). Median follow-up is 3.1 years. CONCLUSIONS: The modified Konno procedure can effectively relieve complex LVOT obstruction and preserve aortic valve function. Extension of this procedure for use in the initial presentation of LVOT may be appropriate in cases at increased risk of recurrent LVOT obstruction.


Subject(s)
Ventricular Outflow Obstruction/surgery , Adolescent , Adult , Child , Child, Preschool , Female , Humans , Infant , Male , Methods , Postoperative Complications , Retrospective Studies
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