Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

Neonatal necrotizing enterocolitis

PURPOSE: A retrospective, 12-year review of neonatal necrotizing enterocolitis was undertaken at a county hospital, with emphasis on presentation signs and symptoms. METHODS: Eighty-two patients with presence of intramural air were included in the study. The following signs and symptoms were studied: evidence of respiratory distress, use of umbilical catheters, white blood cell count and temperature at presentation, time interval from birth to diagnosis and time interval from diagnosis to operative intervention, presence of intramural air, air in biliary tree or free air, changes in abdominal girth, and presence of occult or gross blood in stools. Comparison was done among infants who had surgical or medical treatment, premature and full-term infants, and infants who had neonatal necrotizing enterocolitis less than or more than 20 days after birth. RESULTS: Eleven patients had a fatal outcome, with an overall survival of 87 percent. Sixty-four patients were treated medically and 18 had operative treatment. Mortality of the surgically treated group was 44 percent. Neonates who had surgical intervention had a left shift of the white blood cell count more commonly present, and all had documented abdominal distention. There were 62 premature and 20 full-term neonates in the group. Full-term neonates developed neonatal necrotizing enterocolitis earlier after birth (5.3 days compared with 15.3 days in the premature neonate group). Full-term neonates had a better prognosis in our series. Presentation of symptoms more than 20 days after birth did not change outcome. CONCLUSION: Our results reflect the experience of a community-based hospital. Clinical acumen remains the cornerstone of diagnosis and management.     

Recurrent and residual renal calculi in children

One hundred and thirteen children with non-metabolic urinary tract calculi were operated on between 1960 and 1983. One hundred were followed up for 3 to 17 years (mean 8.2). Seventeen children (15%) developed recurrent calculi after complete clearance at the initial operation and in 13 of these the stones recurred within 5 years. Proteus urinary infection was a constant feature of stone recurrence. Five patients required re-operation for removal of the recurrent calculus. Small residual caliceal fragments were left behind in 17 children but only 3 required surgical removal.     

Congenital posterior urethral polyps in childhood. A case report.

We describe a 3-year-old boy who presented with dysuria and urinary retention. The diagnostic work-up (USS, MRI, urethrocystoscopy), suggested a polypoid lesion at the bladder base, originating from the verumontanum. Histology showed the lesion to be a fibroepithelial polyp. A rare cause of urinary retention in childhood must be considered in the differential diagnosis.     

De Novo Non-Alcoholic Fatty Liver Disease Following Orthotopic Liver Transplantation

Non-alcoholic fatty liver disease (NAFLD) is an increasingly recognized clinico-pathologic entity typically associated with obesity, type II diabetes and hyperlipidemia. It has been noted to recur after orthotopic liver transplantation (OLT). We report four patients who developed de novo NAFLD within 3 months of OLT without the typical predisposing factors of diabetes mellitus or obesity. Three of the four patients underwent OLT for hepatitis C-related cirrhosis, and the other for alcoholic cirrhosis. Examination of the liver explants revealed no evidence of steatosis. No surreptitious alcohol use or a drug-induced process could be identified in these patients. Treatment of recurrent hepatitis C infection in one patient with interferon and ribavirin led to sustained suppression of the viral RNA to undetectable levels, but no improvement in histology or liver enzymes. All four patients had histologic evidence of preservation injury on the initial post-OLT biopsies, but the significance of this finding in relationship to the development of NAFLD is unknown. NAFLD can develop without any of the known predisposing conditions after transplantation, and this raises further questions about the pathogenesis of this condition .     

Undernutrition in the Nursing Home: Prevalence, Consequences, Causes and Prevention

Approximately 5% of Americans over age 65, or 1.5 million individuals, currently reside in the nations's 20,000 nursing homes. The authors present material that lead to three conclusions about this population. First, nutritional deficiencies are common underlying causes of adverse clinical outcomes. Second, nutritional deficiencies are frequently not recognized. Third, opportunities for preventing or correcting undernutrition exist, provided that the significant and reversible nature of the nutrient deficiencies are identified.     

Human lymphocyte antigens (HLA) and Graves' disease in Turkey

To evaluate the association of HLA types with Turkish patients with Graves' disease, HLA typing, clinical findings, and thyroid antibodies were correlated. The HLA types, clinical findings (ophthalmopathy and age at onset), and thyroid stimulating hormone (TSH) receptor (TRAb) and antithyroid microsomal antibodies (MAb) were analyzed. Seventy Turkish patients with Graves' disease and 306 control subjects were assessed. Serological HLA typing was performed in HLA A, B, C, DR, and DQ loci. There was a significantly increased prevalence of HLA B8, B49, DR3, DR4, and DR10 in Graves' disease. The association of Graves' disease with HLA DR3 was found to be less strong than previously described. The HLA DR4 antigen may contribute to the predisposition of Graves' disease in Turkey. The results suggest that HLA B7, B13, DR7, DQw2, and DQw3 may confer a protective effect for Graves' disease in Turkey. Patients carrying HLA B12, B18, and B44 haplotypes had a tendency to develop the disease at a later age. The difference from the other studies may be the result of the selection of the controls; in part, of the variability in serological typing reagents; and, also, of the rather weak HLA associations with the disease.This study was presented in part at the Annual Meeting of the National Endocrinology and Diabetes Association, Bursa, Turkey, May 25–28, 1992.     

Prediction of outcome following necrotizing enterocolitis in a neonatal surgical unit

Retrospective analysis of 27 factors in 80 neonates with necrotizing enterocolitis has enabled us to identify three factors that appear to be of prognostic statistical significance, namely blood pH, platelet count, and the presence of congenital defects. All three factors may be assessed objectively at the time of admission of the patient. Using these factors we have estimated a "probability of death" score for each patient and a high-risk group of neonates has been identified.     

Acute airway obstruction following placement of a subclavian Hickman catheter

The purpose of this case report is to describe the events, intervention, and aetiology which led to acute airway obstruction in an adult patient after the placement of a Hickman catheter. Airway obstruction secondary to superior vena cava obstruction occurred after placement of a subclavian vein Hickman catheter. This was felt to occur, in part, to a narrowed superior vena cava as evident by subclavian venography. It resulted in emergency oral tracheal intubation to relieve airway obstruction. Shortly after removal of the Hickman catheter, the signs of superior vena cava obstruction syndrome resolved and the patient was extubated without incidence. It is concluded that, although rare, the serious complication of acute airway obstruction can occur after placement of a Hickman catheter.     

Clinical significance of technetium-99m methylene diphosphonate myocardial uptake: association with carcinoma of the prostate

Benign myocardial uptake of technetium-99m labelled phosphates, not related to cardiac or metabolic disorders, has been documented except in the case of^99mTc-methylene diphosphonate (MDP). The aim of this study was to assess the frequency of myocardial uptake and its possible association with malignant tumours in general and prostatic carcinoma in particular. We reviewed bone scintigrams performed with either^99mTc-hydroxydiphosphonate (HDP) or^99mTc-MDP over a period of more than 2 years for all patients with prostatic carcinoma and a matching group of patients suffering from other malignant and non-malignant disorders. A total of 965 scintigrams of 812 patients (males=559, females=253; age range 50–91 years, average age 69.2 years) were reviewed. Increased myocardial uptake was detected in 19 scintigrams (MDP=13, HDP=6) of 18 patients (17 males, one female). Most of the male patients with increased myocardial uptake had prostatic carcinoma (13/17) and were over 80 years of age (12/17). All patients were free of any cardiac or noncardiac disorder that might account for such uptake. When scintigraphy was repeated in the same patient, the uptake of^99mTc-HDP was more diffuse and of higher grade than that of^99mTc-MDP Benign myocardial uptake of^99mTc-MDP is more common than previously thought. Although uptake of radiophosphates is attributed to asymptomatic atherosclerotic changes associated with old age, a strong association with prostatic carcinoma exists which may indicate variations in the bone: soft tissue affinity of different MDP complexes.