Heart surgery without previous heart catheterization, in pediatric cardiology]

STUDY OBJECTIVE: To determine the influence of echocardiography in the preoperative diagnosis of heart diseases in children. DESIGN: Retrospective study. SETTING: Hospitalized children admitted in Departments of Pediatric Cardiology and Cardiothoracic Surgery. PATIENTS: Children of both sexes, aged from neonate to 14 years old, with heart disease who underwent cardiac surgery. MATERIAL AND METHODS: From January 1989 to July 1990, 220 consecutive cardiac surgeries were performed in children with heart disease. The initial diagnosis was based on data from clinical examination, electrocardiogram, thorax X-Ray and echocardiogram (M-mode, 2D, conventional and colour Doppler). Patients were separated in three groups according to their ages: newborn infants less than 28 days old; infants less than 12 months old; children more than 1 year old and less than 14 years old. Patients were separated according to the investigations used further for preoperative diagnosis: whether they had or not cardiac catheterization performed prior to surgery. RESULTS: From 220 surgical interventions performed, 124 were "open heart" surgeries (9 neonates, 28 infants and 87 children) and the remaining had "closed heart" operations (14 neonates, 37 infants and 45 children). Preoperative diagnosis was mainly dependent on echocardiography, dispensing catheterization in 90 cardiac interventions. The diagnosis was confirmed at surgery or at autopsy. There were 9 deaths, 3 of which occurred in patients not submitted to cardiac catheterization. CONCLUSIONS: Echocardiography is a reliable method for investigation and establishment of the preoperative diagnosis of heart diseases in children. Its use may further reduce the need for diagnostic catheterization in children, particularly in risk groups.     

Morphofunctional characteristics of the right ventricle in Chagas' dilated cardiomyopathy

Right ventricular involvement is a typical characteristic of Chagas' disease, and it has been described especially in the early stages of the disease. However, the role of right ventricular dysfunction in cardiac failure due to Chagas' cardiomyopathy has not been well established. Seventy-four patients with positive serology tests for Trypanosoma cruzi and Chagas' dilated cardiomyopathy characterized by left ventricular dilatation and systolic dysfunction were studied. Clinical history, physical exam, ECG, chest X-ray and Doppler echocardiogram with color flow mapping were obtained in all. Mean age was 47.5+/-12.9 and 51 were males (69%). Sixty-five patients (88%) were in NYHA functional classes I and II. Mild systolic dysfunction was present in 35 (47%) while in 18 (24%), dysfunction was moderate and in 21 (28%) it was severe. In 43 patients (58%), only the left ventricle was involved by echocardiographic criteria; the remaining 31 patients (42%) showed biventricular involvement. No patient had isolated involvement of the right ventricle. Greater dilation of the right ventricle was associated with larger diastolic (p<0.002) and systolic (p<0.001) diameters of the left ventricle. Systolic pulmonary artery pressure was obtained non-invasively in 54 patients. Pulmonary hypertension was associated with right ventricular dilation (p<0.005) and with systolic dysfunction of the left ventricle (p<0.001). In this group of patients with Chagas' dilated cardiomyopathy, right ventricular dysfunction was present when there was associated and significant involvement of the left ventricle and with higher levels of pulmonary pressure.     

A multivariate analysis of socio-demographic factors, water contact patterns and Schistosoma mansoni infection in an endemic area in Brazil.

Associations between socio-demographic factors, water contact patterns and Schistosoma mansoni infection were investigated in 506 individuals (87% of inhabitants over 1 year of age) in an endemic area in Brazil (Divino), aiming at determining priorities for public health measures to prevent the infection. Those who eliminated S. mansoni eggs (n = 198) were compared to those without eggs in the stools (n = 308). The following explanatory variables were considered: age, sex, color, previous treatment with schistosomicide, place of birth, quality of the houses, water supply for the household, distance from houses to stream, and frequency and reasons for water contact. Factors found to be independently associated with the infection were age (10-19 and > or = 20 yrs old), and water contact for agricultural activities, fishing, and swimming or bathing (Adjusted relative odds = 5.0, 2.4, 3.2, 2.1 and 2.0, respectively). This suggests the need for public health measures to prevent the infection, emphasizing water contact for leisure and agricultural activities in this endemic area.     

Moxalactam for the treatment of bacterial meningitis in children

Increasing resistance to antibiotics in meningeal pathogens has stimulated a search for new antimicrobial agents for the treatment of bacterial meningitis. Moxalactam penetrates well into infected cerebrospinal fluid (CSF) and is highly active against most gram-negative bacteria. The clinical efficacy and safety of moxalactam in the treatment of childhood meningitis caused by Haemophilus influenzae (25 patients) or Neisseria meningitidis (five patients) was evaluated in a random, uncontrolled study. The penetration of the antibiotic into CSF was also evaluated in these patients and in another five children with bacterial meningitis. The clinical results were excellent, with 29 of 30 cases cured. The single adverse clinical reaction noted was the development of a wound hematoma in a postoperative patient; this problem may have been related to moxalactam therapy. The levels of moxalactam achieved in CSF greatly exceeded the minimal bactericidal concentrations for the infecting organisms. Moxalactam appears to be safe and effective as primary therapy for meningitis caused by H influenzae or N meningitidis.     

Efficacy of alternating therapy with oxamniquine and praziquantel to treat Schistosoma mansoni in children following failure of first treatment

Two hundred children infected with Schistosoma mansoni were treated with either 20 mg/kg oxamniquine or 60 mg/kg praziquantel. Cure rates (about 85%) were similar as was the percentage reduction (80%) in egg counts in uncured children. Treatment with the alternative drug of children not cured with the first treatment resulted in negative stools in 11 of 12 cases examined one month after the second round of therapy. In order to minimize the risk of the development of drug resistance, our data suggest that infected patients be treated with one drug, and therapeutic failures with another. Evidence from experiments in mice with isolates obtained after failures of one treatment in children suggests that therapeutic failure does not necessarily indicate the presence of drug-resistant schistosomes. The value of using mice to assess drug resistance in schistosomes is questioned.     

Sinoaortic denervation does not increase cardiovascular/endocrine responses to stress.

Sinoaortic baroreceptor denervation is reported to produce exaggerated centrally derived cardiovascular and endocrine responses. We examined the effect of sinoaortic denervation (SAD) on the cardiovascular and endocrine responses to two acute stressors, footshock and immobilization, in male Sprague-Dawley rats. Parameters measured were mean arterial pressure (MAP), heart rate (HR) and plasma levels of oxytocin (OT) and vasopressin (VP). Baseline MAP was elevated in the SAD group (approximately 25 mm Hg) and footshock stress increased arterial pressure equivalently in both groups. This stress caused tachycardia and increased plasma OT, with a tendency for the SAD group to show blunted responses. Immobilization increased HR but caused no change in MAP and no significant difference between the groups. This form of stress also increased plasma OT, and again the SAD group showed a diminished response. Plasma VP was not significantly altered by either stressor. The results of these studies indicate that SAD does not uniformly increase the cardiovascular and endocrine responses to all stressors or centrally derived stimuli. These results also suggest that the lack of an increase in plasma VP is not related to baroreceptor-mediated inhibition of secretion under stressful conditions.     

Results of percutaneous transseptal mitral commissurotomy in patients 40 years and above with those under 40 years of age: immediate and 5-year follow-up results

Patients with mitral stenosis in Western countries are relatively old. It is anticipated that percutaneous transseptal mitral commissurotomy (PTMC) may have more complications and may not be as effective in this group of patient as in younger patients due to more calcification and fibrosis of the mitral valve. We analysed the clinical, hemodynamic, echocardiographic data in 296 consecutive patients divided prospectively into two groups; group 1 consisted of 184 patients ≥ 40 years and group 2 of 112 patients < 40 years coming mostly from developing countries. The immediate gain in valve area was 2.18 ± 0.61 cm² in group 1 vs. 2.31 ± 0.65 cm² in group 2 (P = ns). The incidence of acute regurgitation requiring surgical intervention was similar in both groups. Follow-up data up to 5 years after PTMC was available in 170 patients (92.4%) in group 1 (mean 20 ± 13 months) and 83 patients (74.1%) in group 2 (mean 29 ± 17 months). Restenosis by Doppler method (valve area less than 1.5 cm² with loss of at least 50% initial gain in valve area) was found in 33 patients in group 1 (29.2%) vs. 11 (14.9%) in group 2 (P < 0.05). Events free from death, need for mitral valve replacement or repeat PTMC at 5 year follow-up was 76% in group 1 vs. 87% in group 2 (P < 0.05). We conclude that the immediate effectiveness and acute complications of PTMC in patients 40 years and above are comparable to younger patients. Restenosis is clearly higher and there is a trend towards need for mitral valve replacement in patients 40 years and above at follow-up. However, the continuing benefit for the majority of the patients 40 years and above (76% free from adverse events) would suggest that PTMC is an appropriate treatment modality even in the older patients. © 1994 Wiley-Liss,Inc..     

Unusual complications after bone marrow transplantation for dyskeratosis congenita

Dyskeratosis congenita (DC) is a rare inherited disorder often associated with aplastic anaemia. We report the cases of five boys transplanted with an HLA-identical related donor for severe aplastic anaemia (SAA) associated to DC; in all cases successful engraftment was observed. Three patients died 2–8 years after bone marrow transplantation (BMT) with signs of endothelial cell damage syndrome (kidney microangiopathy and liver veno-occlusive disease). Another boy died 1 year after BMT from Evans syndrome and invasive aspergillosis. One boy currently presents anaemia, polyarthritis of unknown origin, pulmonary fibrosis and gut malabsorption 7.5 years after BMT. SAA associated with DC can be successfully treated by allogeneic BMT. However, these early and late complications observed are very unusual after BMT and probably reflect the association of transplanted-related factors, evolution of the underlying disease, and increased sensitivity of endothelial cells. Modified conditioning approaches, advances in supportive care and surveillance of these unusual complications offer the possibility of improved outcome for these patients.     

Treatment of iron deficiency anemia with liposomal iron in inflammatory bowel disease: efficacy and impact on quality of life

International Journal of Clinical Pharmacy - Background Anemia is a clinical condition frequently seen in patients with inflammatory bowel disease, which is responsible for a significant loss of...     

Helicobacter pylori Infection in Infants and Toddlers in South America: Concordance between [13C]Urea Breath Test and Monoclonal H. pylori Stool Antigen Test

Accurate noninvasive tests for diagnosing Helicobacter pylori infection in very young children are strongly required. We investigated the agreement between the [¹³C]urea breath test ([¹³C]UBT) and a monoclonal ELISA (HpSA) for detection of H. pylori antigen in stool. From October 2007 to July 2011, we enrolled 414 infants (123 from Brazil and 291 from Peru) of ages 6 to 30 months. Breath and stool samples were obtained at intervals of at least 3 months from Brazilian (n = 415) and Peruvian (n = 908) infants. [¹³C]UBT and stool test results concurred with each other in 1,255 (94.86%) cases (kappa coefficient = 0.90; 95% confidence interval [CI] = 0.87 to 0.92). In the H. pylori-positive group, delta-over-baseline (DOB) and optical density (OD) values were positively correlated (r = 0.62; P < 0.001). The positivity of the tests was higher (P < 0.001; odds ratio [OR] = 6.01; 95% CI = 4.50 to 8.04) in Peru (546/878; 62.2%) than in Brazil (81/377; 21.5%) and increased with increasing age in Brazil (P = 0.02), whereas in Peru it decreased with increasing age (P < 0.001). The disagreement between the test results was associated with birth in Brazil and female gender but not with age and diarrhea. Our results suggest that both [¹³C]UBT and the stool monoclonal test are reliable for diagnosing H. pylori infection in very young children, which will facilitate robust epidemiological studies in infants and toddlers.