Cervical Myelopathy and Peripheral Polyneuropathy in a 26-Year-Old Female Following Bariatric Surgery.

The frequency, clinical course, and prognosis of the neurological sequelae following bariatric surgery remain obscure and continue to be a subject of medical research. We present the case of a 26-year-old female who underwent sleeve gastrectomy for the treatment of obesity and demonstrated progressive neurological deficits within months of her procedure. Extensive testing revealed very low thiamine and copper levels, peripheral polyneuropathy, and spinal cord lesions on imaging. She was treated with intravenous copper and thiamine and was admitted to the rehabilitation unit. Eighteen months following her admission, she achieved complete recovery. Previous studies have reported neurological complications following bariatric surgery in 1.1-8.6% of cases. Some of the most common nutritional deficiencies involve copper, iron, calcium, magnesium, and vitamins B1, B12, D, and E. Patients may experience central and peripheral neurological deficits following bariatric surgery. Fortunately, a path to recovery exists and it involves both pharmacological and rehabilitative treatment.

Long-term prognosis of early repolarization with J-wave and QRS slur patterns on the resting electrocardiogram: a cohort study.

BACKGROUND: The prognostic value of early repolarization with J waves and QRS slurs remains controversial. Although these findings are more prevalent in patients with idiopathic ventricular fibrillation, their ability to predict cardiovascular death has varied across studies. OBJECTIVE: To test the hypothesis that J waves and QRS slurs on electrocardiograms (ECGs) are associated with increased risk for cardiovascular death. DESIGN: Retrospective cohort. SETTING: Veterans Affairs Palo Alto Health Care System. PATIENTS: Veterans younger than 56 years who had resting 12-lead electrocardiography, 90.5% of whom were men. MEASUREMENTS: Electrocardiograms were manually measured and visually coded using criteria of 0.1 mV or greater in at least 2 contiguous leads. J waves were measured at the peak of an upward deflection or notch at the end of QRS, and QRS slurs were measured at the top of conduction delay on the QRS downstroke. Absolute risk differences at 10 years were calculated to study the associations between J waves or QRS slurs and the primary outcome of cardiovascular death. RESULTS: Over a median follow-up of 17.5 years, 859 cardiovascular deaths occurred. Of 20 661 ECGs, 4219 (20%) had J waves or QRS slurs in the inferior and/or lateral territories; of these, 3318 (78.6%) had J waves or QRS slurs in inferior leads and 1701 (40.3%) in lateral leads. The upper bound of differences in risk for cardiovascular death from any of the J-wave or QRS slur patterns suggests that an increased risk can be safely ruled out (inferior, -0.77% [95% CI, -1.27% to -0.27%]; lateral, -1.07% [CI, -1.72% to -0.43%]). LIMITATION: The study consisted of predominantly men, and deaths could be classified as cardiovascular but not arrhythmic. CONCLUSION: J waves and QRS slurs did not exhibit a clinically meaningful increased risk for cardiovascular death in long-term follow-up. PRIMARY FUNDING SOURCE: None.

Examining QRS amplitude criteria for electrocardiographic left ventricular hypertrophy in recommendations for screening criteria in athletes.

BACKGROUND: Current guidelines for interpretation of the ECGs of athletes recommend that isolated R and S wave amplitudes that exceed traditional criteria for left ventricular hypertrophy be accepted as a physiological response to exercise training. This is based on training and echocardiographic studies but not on long term follow up. Demonstration of the prognostic characteristics of the amplitude criteria in a non-athletic population could support the current guidelines. OBJECTIVE: To evaluate the prognostic value of the R and S wave voltage criteria for electrocardiographic left ventricular hypertrophy (ECG-LVH) in an ambulatory clinical population. SUBJECTS AND METHODS: The target population consisted of 20,903 ambulatory subjects who had ECGs recorded between 1987 and 1999 and were followed for cardiovascular death until 2013. During the mean follow up of 17 years, there were 881 cardiovascular deaths. RESULTS: The mean age was 43 ± 10, 91% were male and 16% were African American. Of the 2482 (12%) subjects who met the Sokolow-Lyon criteria, 241 (1.2%) subjects with left ventricular (LV) strain had an HR of 5.4 (95% CI 4.1-7.2, p<0.001), while 2241 (11%) subjects without strain had an HR of 1.4 (95% CI 1.2-1.8, p<0.001). Of the 4836 (23%) subjects who met the Framingham voltage criteria, 350 (2%) subjects with LV strain had an HR of 5.1 (95% CI 4.0-6.5, p<0.001), while 4486 (22%) subjects without strain had an HR of 1.1 (95% CI 0.9-1.3, p=0.26). The individual components of the Romhilt-Estes had HRs ranging from 1.4 to 3.6, with only the voltage component not being significant (HR 1.1, 95% CI 0.9-1.5, p=0.35). CONCLUSIONS: This study demonstrates that the R and S wave voltage criteria components of most of the original classification schema for electrocardiographic left ventricular hypertrophy are not predictive of CV mortality. Our findings support the current guidelines for electrocardiographic screening of athletes.

A new electrocardiographic left ventricular hypertrophy prognostic score.

This report determines if the classic Romhilt-Estes score would predict better if points for its components were determined using a Cox hazard model and if the Cornell voltage criteria should replace the original criteria. Of the 20,903 subjects, the mean age was 43 ± 10 years and 90.6% were men. The mean follow-up for the population was 17 years, with 881 cardiovascular deaths; they were tested from 1987 to 1999 and followed until 2013. The new score was created with multipliers based on the Cox hazards of its elements with age bracket and gender included. The Cornell criteria were analyzed individually using Cox hazards with and without adjustments for age, gender, and African-American ethnicity and subsequently incorporated into the new score for analysis. For the new score, all 7 components were significant predictors of cardiovascular mortality with gender producing the greatest hazard ratio (HR) and left axis deviation and QRS duration >110 ms producing the lowest. For the original Romhilt-Estes score, 367 patients (1.8%) met the "definite" cutoff and had an HR of 5.6 (95% confidence interval 4.3 to 7.1). For the new score, 208 patients (1.0%) met the "definite" left ventricular hypertrophy cutoff and had an HR of 13.6 (95% confidence interval 10.8 to 17.3). The Romhilt-Estes had an area under the curve of 0.63, whereas the new score and new score with Cornell voltage both had an area under the curve of 0.7. In conclusion, our modified Romhilt-Estes score with new multipliers and without voltage criteria outperformed the original score.