Takotsubo syndrome linked to paroxysmal sympathetic hyperactivity as a postoperative complication after brain tumor removal: a case report and literature review.

Paroxysmal sympathetic hyperactivity (PSH) is a relatively common syndrome typically observed following traumatic brain injury (TBI). It manifests through a combination of non-specific symptoms that collectively define its presentation. Linked to sympathetic hyperactivity, takotsubo syndrome is a cardiomyopathy marked by left ventricular dysfunction and may coincide with PSH. While various factors can lead to the simultaneous occurrence of these syndromes, a notably rare scenario involves their manifestation after brain tumor removal. The nonspecific nature of PSH symptoms and of the cardiac dysfunction in takotsubo syndrome pose challenges in accurately diagnosing these conditions in an intensive care unit (ICU) setting. They often overlap with more prevalent diagnoses like sepsis, pulmonary embolism, and acute heart failure. Thus, it is crucial for clinicians dealing with these patients to be aware that symptoms indicating sympathetic activity surge and left heart failure might prompt consideration of takotsubo syndrome and PSH. This study presents the case of an 8-year-old girl who developed takotsubo syndrome associated with sympathetic hyperactivity following the surgical removal of a bulbar tumor. To the best of our knowledge, this is the tenth case of PSH following brain tumor removal in a pediatric patient and the first reported case of occurrence of takotsubo linked to PSH after brain tumor removal. We offer a detailed account of the patient's clinical journey in the ICU, accompanied by a comprehensive review of relevant literature to identify similar cases. The significance of this case study lies in emphasizing the potential occurrence of takotsubo syndrome due to PSH and underscores the importance of early diagnosis and management due to their association with unfavorable clinical outcomes.

Impact of cardiac surgical timing on the neurodevelopmental outcomes of newborns with Complex congenital heart disease (CHD).

Background: More than half of infants with complex congenital heart disease (CHD) will have a neurodevelopmental disorder of multifactorial causes. The preoperative period represents a time-window during which neonates with complex CHD are in a state of hypoxia and hemodynamic instability, which fosters the emergence of brain injuries and, thus, affects early brain networks and neurodevelopmental outcomes. Currently, there is no consensus regarding the optimal age for cardiac surgery in terms of neurodevelopmental outcomes, and its definition is a real challenge. Our aim is to determine the relationship between cardiac surgical timing and long-term neurodevelopmental outcomes for various types of complex CHD. Methods: We hypothesize that earlier surgical timing could represent a neuroprotective strategy that reduces perioperative white matter injuries (WMIs) and postoperative morbidity, leading to improved neurodevelopmental outcomes in infants with complex CHD. Firstly, our prospective study will allow us to determine the correlation between age at the time of surgery (days of life) and neurodevelopmental outcomes at 24 months. We will then analyze the correlation between age at surgery and (i) the incidence of WMIs (through pre- and postoperative MRIs), (ii) postoperative morbidity, and (iii) the duration of the hospital stay. Implications and Dissemination: This research protocol was registered in the Clinical Trial Registry (National Clinical Trial: NCT04733378). This project aims to help launch the first Neurocardiac Investigation Clinic in Marseille - AP-HM - to propose an overall personalized monitoring and treatment program for patients operated on for complex CHD.

Estimating national-level syringe availability to injecting drug users and injection coverage: Switzerland, 1996-2006.

BACKGROUND: Measuring syringe availability and coverage is essential in the assessment of HIV/AIDS risk reduction policies. Estimates of syringe availability and coverage were produced for the years 1996 and 2006, based on all relevant available national-level aggregated data from published sources. METHODS: We defined availability as the total monthly number of syringes provided by harm reduction system divided by the estimated number of injecting drug users (IDU), and defined coverage as the proportion of injections performed with a new syringe, at national level (total supply over total demand). Estimates of supply of syringes were derived from the national monitoring system, including needle and syringe programmes (NSP), pharmacies, and medically prescribed heroin programmes. Estimates of syringe demand were based on the number of injections performed by IDU derived from surveys of low threshold facilities for drug users (LTF) with NSP combined with the number of IDU. This number was estimated by two methods combining estimates of heroin users (multiple estimation method) and (a) the number of IDU in methadone treatment (MT) (non-injectors) or (b) the proportion of injectors amongst LTF attendees. Central estimates and ranges were obtained for availability and coverage. RESULTS: The estimated number of IDU decreased markedly according to both methods. The MT-based method (from 14,818 to 4809) showed a much greater decrease and smaller size of the IDU population compared to the LTF-based method (from 24,510 to 12,320). Availability and coverage estimates are higher with the MT-based method. For 1996, central estimates of syringe availability were 30.5 and 18.4 per IDU per month; for 2006, they were 76.5 and 29.9. There were 4 central estimates of coverage. For 1996 they ranged from 24.3% to 43.3%, and for 2006, from 50.5% to 134.3%. CONCLUSION: Although 2006 estimates overlap 1996 estimates, the results suggest a shift to improved syringe availability and coverage over time.

Experience with remifentanil-sevoflurane balanced anesthesia for abdominal surgery in neonates and children less than 2 years.

BACKGROUND: Few data report remifentanil use in the neonatal population. We described here our experience with remifentanil-sevoflurane balanced anesthesia in neonates and children less than 2 years who underwent general anesthesia for abdominal surgery. METHODS: We retrospectively studied the pattern of remifentanil infusion associated with sevoflurane inhalation in preterm neonates (PTN; n = 18) (born before 37 weeks of gestation and <45 weeks of postmenstrual age), full-term neonates (FTN; n = 21) (born after 37 weeks of gestation and less than 29 days old) and older children up to 2 years (CUT; n = 24). We recorded heart rate (HR), mean arterial pressure (MAP), mean remifentanil dose and sevoflurane concentration before incision and at 5, 10, 20, 30, 45, 60, 90, and 105 min after incision. RESULTS: We observed that remifentanil doses used during surgery were lower in PTN than in both FTN and CUT and lower in FTN than in CUT. This was because of a progressive decrease in remifentanil dose during anesthesia in PTN and FTN. Conversely, remifentanil doses increased in CUT during anesthesia. Sevoflurane concentrations were higher in CUT group than in PTN and FTN groups. MAP and HR did not vary in the three groups during anesthesia. CONCLUSIONS: Remifentanil-sevoflurane anesthesia can be used for general anesthesia in neonates. We observed that anesthetists used lower doses of remifantanil and lower concentrations of sevoflurane in neonates compared with the older children.