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Introduction: In most cases, multiple sclerosis (MS) initially presents as clinically isolated syndrome (CIS). Differentiating CIS from other acute or subacute neurological diseases and estimating the risk of progression to clinically definite MS is essential since presenting a second episode in a short time is associated with poorer long-term prognosis. Development: We conducted a literature review to evaluate the usefulness of different variables in improving diagnostic accuracy and predicting progression from CIS to MS, including magnetic resonance imaging (MRI) and such biofluid markers as oligoclonal IgG and IgM bands, lipid-specific oligoclonal IgM bands in the CSF, CSF kappa free light-chain (KFLC) index, neurofilament light chain (NfL) in the CSF and serum, and chitinase 3–like protein 1 (CHI3L1) in the CSF and serum. Conclusions: Codetection of oligoclonal IgG bands and MRI lesions reduces diagnostic delays and suggests a high risk of CIS progression to MS. A KFLC index > 10.6 and CSF NfL concentrations > 1150 ng/L indicate that CIS is more likely to progress to MS within one year (40%–50%); 90% of patients with CIS and serum CHI3L1 levels > 33 ng/mL and 100% of those with lipid-specific oligoclonal IgM bands present MS within one year of CIS onset. Resumen: Introducción: La mayoría de los pacientes con esclerosis múltiple (EM) debutan con un síndrome clínico aislado (SCA). Es importante diferenciar este SCA de otras patologías neurológicas agudas o subagudas y estimar el riesgo de desarrollar una esclerosis múltiple clínicamente definida (EMCD), pues un segundo ataque clínico en un corto periodo de tiempo se asocia con peor pronóstico a largo plazo. Desarrollo: Se realizó una revisión bibliográfica con el objetivo de contrastar diferentes variables, tales como la resonancia magnética (RM) y diferentes marcadores biofluídicos como las bandas oligoclonales IgG (BOC), bandas oligoclonales IgM (BOCM), bandas oligoclonales IgM lípido específicas (BOCM-LE), índice de cadenas ligeras libres Kappa (κ index) mediante la determinación de las cadenas ligera libres kappa en líquido cefalorraquídeo (LCR), neurofilamentos de cadenas ligeras en LCR (NfLL) y suero (NfLS) y la proteína chitinasa 3-like 1 (CHI3L1) en LCR (CHI3L1L) y suero (CHI3L1S), con el objetivo de mejorar la precisión diagnóstica y predecir los riesgos de un segundo ataque clínico tras un SCA. Conclusión: Unas BOC positivas junto con la identificación de lesiones por RM, reducirán el tiempo de diagnóstico y nos indicaran que la mayoría de los pacientes con SCA evolucionaran a EM. Un κ index >10.6 y una concentración de NfLL > 1150 ng/L, nos indican que los SCA tienen más probabilidades de convertirse en EM durante el primer año (40%/50%). El 90% de los pacientes con SCA y niveles de CHI3L1S >33 ng/mL, y el 100% con presencia BOCM-LE se convierten en EM durante el primer año.

Resumen: Introducción: La mayoría de los pacientes con esclerosis múltiple (EM) debutan con un síndrome clínico aislado (SCA). Es importante diferenciar este SCA de otras patologías neurológicas agudas o subagudas y estimar el riesgo de desarrollar una esclerosis múltiple clínicamente definida (EMCD), pues un segundo ataque clínico en un corto período de tiempo se asocia con peor pronóstico a largo plazo. Desarrollo: Se realizó una revisión bibliográfica con el objetivo de contrastar diferentes variables, tales como la resonancia magnética (RM) y distintos marcadores biofluídicos como las bandas oligoclonales IgG (BOC), bandas oligoclonales IgM (BOCM), bandas oligoclonales IgM lípido específicas (BOCM-LE), índice de cadenas ligeras libres Kappa (κ index) mediante la determinación de las cadenas ligeras libres kappa en líquido cefalorraquídeo (LCR), neurofilamentos de cadenas ligeras en LCR (NfLL) y suero (NfLS) y la proteína chitinasa 3-like 1 (CHI3L1) en LCR (CHI3L1L) y suero (CHI3L1S), con el objetivo de mejorar la precisión diagnóstica y predecir los riesgos de un segundo ataque clínico tras un SCA. Conclusión: Unas BOC positivas junto con la identificación de lesiones por RM, reducirán el tiempo de diagnóstico y nos indicarán que la mayoría de los pacientes con SCA evolucionarán a EM. Un κ index > 10,6 y una concentración de NfLL > 1.150 ng/L, nos muestran que los SCA tienen más probabilidades de convertirse en EM durante el primer año (40/50%). El 90% de los pacientes con SCA y niveles de CHI3L1S > 33 ng/mL, y el 100% con presencia BOCM-LE se transforman en EM durante el primer año. Abstract: Introduction: In most cases, multiple sclerosis (MS) initially presents as clinically isolated syndrome (CIS). Differentiating CIS from other acute or subacute neurological diseases and estimating the risk of progression to clinically definite MS is essential since presenting a second episode in a short time is associated with poorer long-term prognosis. Development: We conducted a literature review to evaluate the usefulness of different variables in improving diagnostic accuracy and predicting progression from CIS to MS, including magnetic resonance imaging (MRI) and such biofluid markers as oligoclonal IgG and IgM bands, lipid-specific oligoclonal IgM bands in the CSF, CSF kappa free light-chain (KFLC) index, neurofilament light chain (NfL) in the CSF and serum, and chitinase 3–like protein 1 (CHI3L1) in the CSF and serum. Conclusions: Codetection of oligoclonal IgG bands and MRI lesions reduces diagnostic delays and suggests a high risk of CIS progression to MS. A KFLC index > 10.6 and CSF NfL concentrations > 1150 ng/L indicate that CIS is more likely to progress to MS within one year (40-50%); 90% of patients with CIS and serum CHI3L1 levels > 33 ng/mL and 100% of those with lipid-specific oligoclonal IgM bands present MS within one year of CIS onset.

Introduction: The precise pathophysiology of common atrial flutter remains imperfectly known. The mechanisms of arrhythmia initiation and the role of areas of slow conducting myocardium and functional block are still debated topics., Methods: We conducted a detailed electrophysiological study of a patient to illustrate and refine these concepts. Prior to CTI ablation, electrophysiological study and electro-anatomical mapping were performed, focusing on initiation and maintenance mechanisms of the arrhythmia., Results: The initiation of common atrial flutter takes place on the septal aspect of the cavo-tricuspid isthmus where functional unidirectional conduction block occurs. The direction of activation is therefore frequently counter-clockwise, and the arrhythmia stabilizes around the vena cavas and sinus venosus/crista terminalis region. No conduction slowing is present., Conclusions: Common atrial flutter initiates when functional unidirectional conduction block occurs on the septal cavotricuspid isthmus. Its rotation is limited by anatomical and functional boundaries., Competing Interests: JD received modest consulting fees and speaking honoraia from Biosense Webster. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Arnaud, Sacristan, Hocini, Jais, Haissaguerre and Duchateau.)

Background: Pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) increasingly automatically record and remotely transmit nonsustained ventricular tachycardia (NSVT) episodes, which may reveal ventricular oversensing., Objectives: We aimed to develop and validate a machine learning algorithm that accurately classifies NSVT episodes transmitted by PMs and ICDs in order to lighten health care workload burden and improve patient safety., Methods: PMs or ICDs (Boston Scientific, St Paul, MN) from 4 French hospitals with ≥1 transmitted NSVT episode were split into 3 subgroups: training set, validation set, and test set. Each NSVT episode was labeled as either physiological or nonphysiological. Four machine learning algorithms-2DTF-CNN, 2D-DenseNet, 2DTF-VGG, and 1D-AgResNet-were developed using training and validation data sets. Accuracies of the classifiers were compared with an analysis of the remote monitoring team of the Bordeaux University Hospital using F2 scores (favoring sensitivity over predictive positive value) using an independent test set., Results: A total of 807 devices transmitted 10,471 NSVT recordings (82% ICD; 18% PM), of which 87 devices (10.8%) transmitted 544 NSVT recordings with nonphysiological signals. The classification by the remote monitoring team resulted in an F2 score of 0.932 (sensitivity 95%; specificity 99%) The 4 machine learning algorithms showed high and comparable F2 scores (2DTF-CNN: 0.914; 2D-DenseNet: 0.906; 2DTF-VGG: 0.863; 1D-AgResNet: 0.791), and only 1D-AgResNet had significantly different labeling from that of the remote monitoring team., Conclusion: Machine learning algorithms were accurate in detecting nonphysiological signals within electrograms transmitted by PMs and ICDs. An artificial intelligence approach may render remote monitoring less resourceful and improve patient safety., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the agreement of smartwatch-derived single-lead electrocardiogram (ECG) recordings with 12-lead ECGs for diagnosing electrocardiographic abnormalities., Study Design: A 12-lead ECG and an ECG using Apple Watch were obtained in 110 children (aged 1 week to 16 years) with normal (n = 75) or abnormal (n = 35) 12-lead ECGs (atrioventricular block [7], supraventricular tachycardia [SVT] {5}, bundle branch block [12], ventricular preexcitation [6], long QT [5]). In children aged <6 years, the ECG recording was performed with the active participation of an adult who applied the neonate or child's finger to the crown of the watch. In older children, tracings were obtained after brief teaching without adult guidance. All 12-lead ECGs were independently evaluated by 2 blinded cardiologists. Apple Watch ECGs were independently evaluated by another blinded cardiologist., Results: In 109 children (99.1%), the smartwatch tracing was of sufficient quality for evaluation. Smartwatch tracings were 84% sensitive and 100% specific for the detection of an abnormal ECG. All 75 normal tracings were correctly identified. Of the 35 children with abnormalities on 12-lead ECGs, 5 (14%) were missed, most often because of baseline wander and artifacts. Rhythm disorders (atrioventricular block or SVT) and bundle branch blocks were correctly detected in most cases (11 of 12 and 11 of 12, respectively); preexcitation and long QT was detected in 4 of 6 and 4 of 5, respectively., Conclusion: Smartwatch ECGs recorded with parental assistance in children aged up to 6 years and independently in older children have the potential to detect clinically relevant conditions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The accuracy of smartwatch ECG recordings in adults has been demonstrated primarily in the automated diagnosis of atrial fibrillation. While the detection of atrial fibrillation is a priority among adults given the arrhythmia's prevalence and actionable ramifications, the potential value of smartwatch ECG recordings in children differs considerably. In this case series, we will describe some examples of smartwatch ECGs recorded in children, highlighting the feasibility and potential indications of this technology in the pediatric population., Competing Interests: Declaration of Competing Interest The authors report that they have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Combination therapy with hydroxychloroquine and darunavir/ritonavir or lopinavir/ritonavir has been suggested as an approach to improve the outcome of patients with moderate/severe COVID-19 infection., Objectives: To examine the safety of combination therapy with hydroxychloroquine and darunavir/ritonavir or lopinavir/ritonavir., Methods: This was an observational cohort study of patients hospitalized for COVID-19 pneumonia treated with hydroxychloroquine and darunavir/ritonavir or lopinavir/ritonavir. Clinical evaluations, electrocardiograms and the pharmacokinetics of hydroxychloroquine, darunavir and lopinavir were examined according to clinical practice and guidelines., Results: Twenty-one patients received hydroxychloroquine with lopinavir/ritonavir (median age 68 years; 10 males) and 25 received hydroxychloroquine with darunavir/ritonavir (median age 71 years; 15 males). During treatment, eight patients (17.4%) developed ECG abnormalities. Ten patients discontinued treatment, including seven for ECG abnormalities a median of 5 (range 2-6) days after starting treatment. All ECG abnormalities reversed 1-2 days after interrupting treatment. Four patients died within 14 days. ECG abnormalities were significantly associated with age over 70 years, coexisting conditions (such as hypertension, chronic cardiovascular disease and kidney failure) and initial potential drug interactions, but not with the hydroxychloroquine concentration., Conclusions: Of the patients with COVID-19 who received hydroxychloroquine with lopinavir or darunavir, 17% had ECG abnormalities, mainly related to age or in those with a history of cardiovascular disease., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Patients with hepatitis C virus (HCV) genotype 4 infection are poorly represented in clinical trials of second-generation direct-acting antiviral agents (DAAs). More data are needed to help guide treatment decisions. We investigated the effectiveness and safety of DAAs in patients with genotype 4 infection in routine practice. In this cohort study, HCV genotype 4-infected patients treated with ombitasvir/paritaprevir/ritonavir (OMV/PTVr) + ribavirin (RBV) (n=122) or ledipasvir/sofosbuvir (LDV/SOF) ± RBV (n=130) included in a national database were identified and prospectively followed up. Demographic, clinical and virologic data and serious adverse events (SAEs) were analyzed. Differences between treatment groups mean that data cannot be compared directly. Overall sustained virologic response at Week 12 post treatment (SVR12) was 96.2% with OMV/PTVr+RBV and 95.4% with LDV/SOF±RBV. In cirrhotic patients, SVR12 was 91.2% with OMV/PTVr+RBV and 93.2% with LDV/SOF±RBV. There was no significant difference in SVR12 according to degree of fibrosis in either treatment group (P = .243 and P = .244, respectively). On multivariate analysis, baseline albumin <3.5 g/dL (OMV/PTVr) and bilirubin >2 mg/dL (both cohorts) were significantly associated with failure to achieve SVR (P < .05). Rates of SAEs and SAE-associated discontinuation were 5.7% and 2.5%, respectively, in the OMV/PTVr subcohort and 4.6% and 0.8%, respectively, in the LDV/SOF subcohort. DAA-based regimens returned high rates of SVR12, comparable to limited data from clinical trials, in cirrhotic and non-cirrhotic HCV genotype 4 patients managed in a realworld setting. Safety profiles of both regimens were good and comparable to those reported for other HCV genotypes., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)