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; and The Z-score Project 2nd Stage Study Group IMPORTANCE Few studies with sufficient statistical power have shown the association of the z score of the coronary arterial internal diameter with coronary events (CE) in patients with Kawasaki disease (KD) with coronary artery aneurysms (CAA). OBJECTIVE To clarify the association of the z score with time-dependent CE occurrence in patients with KD with CAA. DESIGN, SETTING, AND PARTICIPANTS This multicenter, collaborative retrospective cohort study of 44 participating institutions included 1006 patients with KD younger than 19 years who received a coronary angiography between 1992 and 2011. MAIN OUTCOMES AND MEASURES The time-dependent occurrence of CE, including thrombosis, stenosis, obstruction, acute ischemic events, and coronary interventions, was analyzed for small (z score, <5), medium (z score, Ն5 to <10; actual internal diameter, <8 mm), and large (z score, Ն10 or Ն8 mm) CAA by the Kaplan-Meier method. The Cox proportional hazard regression model was used to identify risk factors for CE after adjusting for age, sex, size, morphology, number of CAA, resistance to initial intravenous immunoglobulin (IVIG) therapy, and antithrombotic medications. RESULTS Of 1006 patients, 714 (71%) were male, 341 (34%) received a diagnosis before age 1 year, 501 (50%) received a diagnosis between age 1 and 5 years, and 157 (16%) received a diagnosis at age 5 years or older. The 10-year event-free survival rate for CE was 100%, 94%, and 52% in men (P < .001) and 100%, 100%, and 75% in women (P < .001) for small, medium, and large CAA, respectively. The CE-free rate was 100%, 96%, and 79% in patients who were not resistant to IVIG therapy (P < .001) and 100%, 96%, and 51% in patients who were resistant to IVIG therapy (P < .001), respectively. Cox regression analysis revealed that large CAA (hazard ratio, 8.9; 95% CI, 5.1-15.4), male sex (hazard ratio, 2.8; 95% CI, 1.7-4.8), and resistance to IVIG therapy (hazard ratio, 2.2; 95% CI, 1.4-3.6) were significantly associated with CE. CONCLUSIONS AND RELEVANCE Classification using the internal diameter z score is useful for assessing the severity of CAA in relation to the time-dependent occurrence of CE and associated factors in patients with KD. Careful management of CE is necessary for all patients with KD with CAA, especially men and IVIG-resistant patients with a large CAA.

Na(x) is the sodium-level sensor of body fluids in the brain involved in sodium homeostasis. Na(x)-knockout mice do not stop ingesting salt even when dehydrated. Here we report a case with clinical features of essential hypernatremia without demonstrable hypothalamic structural lesions, who was diagnosed as a paraneoplastic neurologic disorder. The patient had autoantibodies directed against Na(x), along with a ganglioneuroma composed of Schwann-like cells robustly expressing Na(x). The removal of the tumor did not reduce the autoantibody levels or relieve the symptoms. Intravenous injection of the immunoglobulin fraction of the patient's serum into mice induced abnormalities in water/salt intake and diuresis, which led to hypernatremia. In the brains of these mice, cell death was observed along with focal deposits of complement C3 and inflammatory infiltrates in circumventricular organs where Na(x) is specifically expressed. Our findings thus provide new insights into the pathogenesis of hypernatremia relevant to the sodium-level-sensing mechanism in humans.

Stable isotope ratios (18O/16O, 13C/12C, and 17O/16O) in carbonates have contributed greatly to the understanding of Earth and planetary systems, climates, and history. The current method for measuring isotopologues of CO2 derived from CaCO3 is primarily gas-source isotope ratio mass spectroscopy (IRMS). However, IRMS has drawbacks, such as mass overlap by multiple CO2 isotopologues and contaminants, the requirement of careful sample purification, and the use of major instrumentation needing permanent installation and a high power electrical supply. Here, we report simultaneous 18O/16O, 13C/12C, and 17O/16O analyses for microgram quantities of CaCO3 using a tunable mid-infrared laser absorption spectroscopy (TILDAS) system, which has no mass overlap problem and yields high sensitivity/precision measurements on small samples, as small as 0.02 μmol of CO2 (equivalent to 2 μg of CaCO3) with standard errors of less than 0.08 ‰ for 18O/16O and 13C/12C (±0.136 ‰ and ±0.387 ‰ repeatability; n = 10). In larger samples of CO2, 0.68 μmol (or 68 μg of CaCO3), standard error is less than 0.04 ‰ for 18O/16O and 13C/12C (< ±0.1 ‰ repeatability; n = 10) and 0.03 ‰ for 17O/16O (±0.069 ‰ repeatability; n = 10). We also show, for the first time, the relationship between 17O/16O ratios measured using the TILDAS system and published δ17O values of international standard materials (NBS-18 and −19) measured by IRMS. The benchtop TILDAS system, with cryogen-free sample preparation vacuum lines for microgram quantities of carbonates, is therefore a significant advance in carbonate stable isotope ratio geochemistry and is a new alternative to conventional IRMS.

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