Giant ovarian cyst mimicking ascites

A 60-year-old female patient presented to our clinic with complaints of abdominal distention. The rapid accumulation of fluid was originally thought to be ascites, based on ultrasonographic examination. The cause, however, was ultimately determined to be a borderline malignant giant ovarian cyst. Several processes can mimick ascites: bladder distention or diverticulum, hydronephrosis, pancreatic pseudocysts, and large uterine or ovarian tumors. For this reason, clinicians must consider processes other than ascites in the differential diagnosis of large abdominal fluid accumulation.

Normal early infant behaviour patterns

As part of a wider study, infant behaviour was reviewed prospectively, using a 24 h diary completed by the mother. Infants' sleep, awake, fussing, crying and feeding behaviour were recorded at 1,2,4,6 and 8 weeks. Completed records were obtained from 21 infants. As expected most time was spent asleep, with a mean of 16.2 h at 1 week and 15.5 h at 8 weeks. Most sleeping occurred between midnight and 4 a.m. even by week 1 and there was a progressive fall in the average duration of feeding during that time interval over the 8 week period. Fussing and crying were mostly noted between 4 and 8 p.m. with an additional peak between 8 a.m. and noon, the latter disappearing by week 4. There was also a progressive drop in both the average feeding and fussing/crying times by week 8, reflecting increased settled and awake periods. It is against a background of normal early infant behaviour patterns that one can evaluate interventions aimed at altering such behaviour and dealing with the vexed problem of 'colic'.

Conservation-withdrawal reaction in infancy? An underdescribed entity

Conservation-withdrawal is considered a biological non-pathological process subserving survival in circumstances which pose an extreme threat to an infant, child or adult. Although initially described in an infant, is reported frequency in that age group seems sparse. Four infants are described, three of whom presented with weight loss. Despite their mothers' assertions that their breast feeding was adequate, the three infants gained weight rapidly on complementary feeding and became more responsive. Previously they had passively accepted sub-optimal intakes, crying little and sleeping excessively. When their initial crying and objection went unheeded, they seemed to pass into a conservation-withdrawal state, conserving their energies, biologically adapting to their mothers' inability to provide adequate nutrition. These infants did not appear ill and investigations proved normal. With adequate feeding, rapid improvement was observed in their weight gain, activity and responsiveness with normal development. Their mothers' selective denial of their own inadequate breast supply resulted in their inability to perceive their infants appropriately, depriving them of their nutritional needs. Additional factors of emotional deprivation and neglect may have occurred in the fourth infant. The responses of these infants observed during their period of severe stress, may appropriately be characterised by Engel's conservation-withdrawal state.

Prevention of heart disease by subcutaneous desferrioxamine in patients with thalassaemia major

BACKGROUND

Cardiac siderosis from transfused iron remains the major cause of death in thalassaemia major, despite iron chelation therapy with desferrioxamine.

AIMS

Our aim was to determine the nature and extent of cardiac involvement and its relationship to desferrioxamine use in a group with thalassaemia major.

METHODS

We reviewed 76 patients with thalassaemia major and performed multiple logistic regression to analyse factors affecting cardiac involvement. Factors studied included: patient sex, age, haemoglobin, serum ferritin, total transfusions, liver iron, duration of desferrioxamine use, electrocardiograms, echocardiograms and compliance to desferrioxamine treatment.

RESULTS

Thirty-seven patients developed heart disease. They were older (p < 0.001), began desferrioxamine later (p < 0.001), had more liver iron (p = 0.014), higher serum ferritin levels (p = 0.023) and received more blood (p = 0.018). Compared to those with optimal compliance the odds of developing heart disease were increased 10.7 times in fair compliers (p < 0.001) and 5.1 times in poor compliers (p = 0.016). However, there was no significant difference between those with fair and poor compliance. After multivariate analysis only compliance (p = 0.02) and age at desferrioxamine onset (p = 0.004) remained significant. Compliance was inversely related to liver iron (p < 0.001), serum ferritin (p < 0.001) and age at desferrioxamine commencement (p < 0.001).

CONCLUSIONS

We conclude that late commencement of desferrioxamine and noncompliance are associated with greater iron loading and an increased risk of heart disease.

Cardiac arrhythmias as a manifestation of acquired heart disease in association with paediatric respiratory syncitial virus infection

Respiratory syncitial virus (RSV) is a common cause of upper and lower respiratory tract infection in infants. An association between RSV bronchiolitis and cardiac arrhythmias has been described but is rare. A further case of an infant with supraventricular tachycardia in association with culture-positive respiratory syncitial virus bronchiolitis is reported. This case prompted a review of the two other cases of arrhythmia associated with RSV infection seen at this institution and a review of all other published cases.

Long-term follow-up after two coronary repair of anomalous left coronary artery from the pulmonary artery

A retrospective analysis of ten patients with anomalous left coronary artery arising from the pulmonary artery operated between 1979 and 1990 was undertaken. All presented with evidence of left ventricular dysfunction and "ischemic" mitral regurgitation. Surgical repair consisted of an aortopulmonary tunnel (Takeuchi) procedure in eight and direct left coronary artery reimplantation in two. Two patients required postoperative support with a left ventricular assist device. There were no operative or late deaths (CL 0% to 17%) for a follow-up of over 670 patient months. All patients are in New York Heart Association Class I or II, though two patients are still receiving anticongestive medications. One patient has required further surgery for pulmonary artery stenosis, and another has had a mitral valve replacement because of severe mitral regurgitation. One additional patient has moderate-to-severe residual mitral regurgitation and two have a trivial left coronary to main pulmonary artery fistula. All have a patent, nonstenotic left coronary artery and much improved left ventricular function and perfusion as assessed by echocardiography, thallium scan, gated blood pool scan, and angiography. There have been no documented arrhythmias, clinically or on Holter monitoring. The ECGs have shown resolution or improvement of the initial changes of ischemia/infarction in all patients. Chest X-rays have shown normalization of cardiothoracic ratio in eight of ten patients. Excellent early and late results can be achieved following timely surgical repair. Marked improvement in left ventricular function has been observed in patients with poor preoperative left ventricular function, even in the presence of extensive ischemia/infarction.

Charting infant distress: an aid to defining colic

The value of a 24-hour distress diary, previously validated against a voice-activated audiotape record, was investigated in 30 infants with colic and 30 control infants. The infants with colic had significantly more distress behavior (300.0 minutes vs 102.5 minutes; p < 0.001), although overlap of duration of distress was noted. On the basis of a clinical definition of colic--total distress lasting 180 minutes in a 24-hour period--the diary had a sensitivity of 77% and a specificity of 87%. The sensitivity of the chart was confirmed in a separate study of another 90 infants with colic.

Interrupted aortic arch in infancy: a 10-year experience

Fifty infants with interrupted aortic arch (IAA), admitted between 1979 and 1988, were reviewed. They usually presented early in severe cardiac failure or shock. In the initial 5-year period, 17 of the 21 infants underwent diagnostic or confirmatory cardiac catheterization, in contrast with the latter 5 years when only eight of the subsequent 29 patients underwent catheterization. Since 1987, all patients underwent surgery after cross-sectional echocardiography. Fifteen infants had a type A IAA and 35 had type B. All had associated cardiac anomalies. Four infants were not operated on. In the initial 5-year period, of 17 infants who were surgically treated, four had a one-stage total repair, the remaining had a two-stage repair with initial reconstruction of the arch and pulmonary artery banding. There was an overall surgical mortality of 65%, reflecting the precarious state of many of these infants before surgery with a significant contribution from unrelieved subaortic stenosis. In the latter 5-year period, 29 underwent surgery, 22 had a one-stage total repair. There were three deaths, all in infants whose active treatment was withdrawn. The outcome of the survivors has generally been good, subsequent surgery being mainly related to the associated anomalies (e.g., recurrent subaortic stenosis, conduit replacement). Over this 10 year period the greater accuracy of noninvasive diagnoses, and perioperative intensive care, have led to an improvement in the preoperative state of these infants. Single-stage total repair is our procedure of choice.

Case studies in adolescent deliberate self-harm

Four adolescents admitted to a general paediatric ward at a teaching hospital with deliberate self-harm were reviewed. Their initial psychosocial assessment was noted together with their subsequent course 12 months later. Despite an extensive assessment by a multidisciplinary team during the initial admission, follow-up 12 months later revealed that each subject appeared to have ongoing problems. This outcome raised doubts as to the appropriateness and effectiveness of a prolonged hospital admission in their initial assessment. The difficulties encountered with their management are highlighted.

Prevention of peripheral side-effects of transdermal hyoscine by adjunctive therapy with low dosage of pyridostigmine

1. The value of low dosage of pyridostigmine (30 mg three times daily) in preventing peripheral anti-muscarinic side effects of a transdermal controlled-release formulation of hyoscine, was tested in a double-blind placebo-controlled study, involving 47 healthy subjects. 2. Salivary excretion was repeatedly measured during 48 h of combined therapy of two transdermal hyoscine patches with pyridostigmine and 14 h after its cessation. Blood acetylcholinesterase activity was also measured, serving as an index of pyridostigmine bioavailability. 3. The adjunctive therapy with pyridostigmine was highly effective in preventing the substantial impairment in salivary flow caused by the transdermal formulation. An associated 23% inhibition of blood acetylcholinesterase activity was observed. 4. Small doses of pyridostigmine may therefore have a role in increasing the tolerability of transdermal hyoscine therapy. In some patients this drug combination might also allow some increment of the hyoscine dose.

Cardiac conduction abnormalities and rhythm changes after neonatal anatomical correction of transposition of the great arteries

Seventy three infants who underwent neonatal anatomical correction for transposition of the great arteries with or without a ventricular septal defect were reviewed for evidence of conduction and rhythm abnormalities on preoperative and postoperative 12 lead electrocardiograms and during 24 hour Holter monitoring. There was a partial right bundle branch block pattern in 47% (29/62) of all patients and in 60% (24/40) of those with simple transposition. Complete right bundle branch block was noted in 21% including 5% with simple transposition. Holter monitoring showed sinus rhythm in all patients except three: one had episodes of supraventricular tachycardia, another an intermittent second degree heart block, and a third a complete heart block. Atrial extrasystoles were noted in 47% (29/62) of patients but were frequent in only three patients. Occasional unifocal ventricular extrasystoles were encountered in 37% (23/62) of patients and were frequent in a further 3% (2/62). Only one patient (2%) developed multifocal ventricular extrasystoles. The frequency of important cardiac arrhythmias after neonatal anatomical correction of transposition of the great arteries was 5%, significantly less than that reported after atrial inflow diversion for the same malformation.

Fetal arrhythmias: a 3-year experience

Eight cases of fetal arrhythmia were seen over a 3-year period. Two had atrial and/or ventricular extrasystoles, 1 had complete atrioventricular block and 5 had tachyarrhythmias--3 supraventricular tachycardia, 1 atrial flutter and 1 ectopic atrial tachycardia. All had structurally normal hearts. Nonimmune hydrops fetalis was the initial presentation in 3 of the 5 cases with tachyarrhythmias. There were 2 deaths--a stillbirth and a neonatal death, while 2 others required neonatal intensive care. The 6 survivors have remained well and are now off treatment. The diagnosis, careful assessment and management of a fetal arrhythmia may lead to a successful outcome. The complexity of the problems experienced may warrant early referral to a tertiary centre where the overall management of the mother, fetus and neonate, may be undertaken.

Endomyocardial biopsy in infants and children with cardiomyopathy

We reviewed our experience of endomyocardial biopsy performed on 21 symptomatic infants and children with cardiomyopathy. Clinical congestive cardiomyopathy was noted in 18 patients, 2 had hypertrophic cardiomyopathy, and 1 a restrictive cardiomyopathy. The biopsy findings led to a diagnosis of hemochromatosis in one patient, Adriamycin cardiomyopathy in another, and lymphocytic myocarditis in a third. Five patients had features of endocardial fibroelastosis, one endomyocardial fibrosis, and a further one, a mitochrondrial abnormality. In 11 patients normal or nonspecific features were seen. There were 2 myocardial perforations, both patients being successfully resuscitated. Endomyocardial biopsy, although occasionally hazardous, may sometimes provide valuable information which may lead to a diagnosis, facilitate treatment, and be of prognostic value. Despite the low positive yield, it may still be indicated in selected patients, in view of the seriousness and often poor prognosis of this disorder: 5 of our study group subsequently died.

Severe subaortic stenosis in interrupted aortic arch in infancy and childhood

Thirteen out of a total 50 infants with interrupted aortic arch (IAA) seen between 1979-1988 had or developed severe subaortic stenosis (SAS). One had type A interruption and 12 type B. All had a large ventricular septal defect (VSD). The infundibular septum was displaced posteriorly in eight infants, severely narrowing the left ventricular outflow tract (LVOT). Three had fibromuscular narrowing of the LVOT, one each a subaortic muscle bar and membrane. The aortic root and subaortic area were small and measured between 3-8 mm. An anomalous right subclavian artery was noted in eight of the 12 type B IAA, the anomalous vessel arising from the descending aorta in seven. Thirteen infants with IAA and SAS were submitted to surgery, 12 having their subaortic area resected with three perioperative deaths early in the series and three late deaths where active treatment was ceased, including one infant with renal dysplasia who had had a successful establishment of arch continuity and pulmonary artery banding. Of the seven survivors, six have residual Doppler gradients of between 20-50 mmHg, two requiring a second resection and one a third resection. Alternate management programs are suggested based on anatomical evaluation and echocardiography. Any newborn presenting with IAA requires careful evaluation of the subaortic area, best seen on cross-sectional echocardiography. The improved surgical survival in infants following complete repair of IAA has led this important associated anomaly of subaortic stenosis to assume greater importance as a cause of mortality and long-term morbidity.

Respiratory syncytial virus and supraventricular tachycardia in an infant

A 7-week infant admitted with bronchiolitis proven to be caused by respiratory syncytial virus developed a supraventricular tachycardia which responded to digitalization. She has remained well and no longer requires medication 6 months later, her electrocardiogram now being normal. The course of the illness suggests an association between infection with respiratory syncytial virus and the development of the tachycardia.

Early surgical closure of a large ventricular septal defect: influence on long-term growth

The pre- and postoperative growth patterns of 52 otherwise normal infants undergoing primary surgical closure of a large ventricular septal defect before 7 months of age were reviewed. Serial measurements of weight, length and head circumference were compiled for all patients preoperatively and in 46 long-term survivors and were expressed as Z scores (in standard deviations from the mean for age and gender). By the time of surgery at a mean age of 0.33 year, the mean weight, length and head circumference Z scores of all 52 infants were -2.9, -0.9 and -0.6, respectively, and were all significantly below normal (p less than 0.001). At a mean age of 5.7 years, the mean weight, length and head circumference Z scores of 35 patients of normal birth weight were normal or varied only marginally from those of the reference population (-0.4, -0.1 and +0.5, respectively; p less than 0.02, p greater than 0.05 and p = 0.008, respectively) and did not differ significantly in any variable from those of 44 normal siblings. However, among 11 infants with a low birth weight, all three variables remained abnormal at long-term follow-up when compared with the reference population (-1.7, -1.7 and -0.9, respectively; p less than 0.001 for each) and 22 normal siblings (p less than or equal to 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)

Valvar vegetations in the neonate due to fetal endocarditis

Mass lesions were observed on the tricuspid valve by cross-sectional echocardiography in 5 neonates, 4 of whom presented with fetal distress. Four went on to develop severe respiratory distress, 3 from meconium aspiration and 1 from hyaline membrane disease, with 2 deaths despite intensive treatment. Autopsy confirmed meconium aspiration pneumonia. Sterile, unorganised vegetations were seen on the tricuspid valve (and in 1 infant the mitral valve too). Perinatal factors such as hypoxia, haemodynamic and coagulation disturbances may have contributed to the formation of the vegetations and may reflect the severity and refractoriness of persistent pulmonary hypertension.

Familial fixed subaortic stenosis

In this report, we give details of two families in which fixed subaortic stenosis was found in more than one member. It is rare for this entity to show familial incidence.