A rare cause of hemoptysis in childhood: peripheral pulmonary artery pseudoaneurysm to bronchial fistula in a case with tetralogy of Fallot

We herein report a patient complaining from significant hemoptysis due to secondary fistulisation of the peripheral branch of the left pulmonary artery and the left bronchial tree, which was successfully treated with a transcatheter angiography.

Short-term efficacy of ORS formulation and propranolol regimen in children with POTS

BACKGROUND

To evaluate the short-term effectiveness of reduced-osmolarity oral rehydration salt formulation (ORS) and propranolol in children diagnosed with postural orthostatic tachycardia syndrome (POTS) in head-up tilt testing (HUTT).

METHODS

Children were admitted with symptoms of orthostatic intolerance (OI) occurring in a standing position and disappearing in the supine position. Patients with heart rate increments of ≥40bpm and symptoms of OI constituted the pediatric POTS group in HUTT. A total of 70 pediatric patients with POTS were included in the study. POTS patients were divided into two groups based on whether they were prescribed reduced-osmolarity ORS and propranolol or not. The study group comprised patients on a regimen of reduced-osmolarity ORS and propranolol (n=34), while the control group comprised patients who were not prescribed any medication (n=36). The frequency of symptoms and standardized symptom scores were analyzed before and after 3 months of treatment in both groups.

RESULTS

The post-treatment frequency of syncopal attacks was significantly reduced in both groups (P<0.01 for both groups), but the post-treatment standardized symptom scores were significantly reduced in the pediatric study group compared with the control group (P<0.01).

CONCLUSION

The frequency of syncopal attacks was significantly reduced and the symptom scores for OI were improved in the study group. The improvement in OI symptom scores was better in the treatment group than in the control group. The control group symptoms persisted and caused extreme difficulty in their daily activities. In view of its clinical efficacy, we strongly advocate the use of combined treatment of reduced-osmolarity ORS and low-dose propranolol in pediatric patients with POTS.

Risk Factors Associated with Ascending Aortic Aneurysms and Aortic Elasticity Parameters in Children with a Bicuspid Aortic Valve

Aneurysms of the ascending aorta are frequently found in patients with a bicuspid aortic valve (BAV). This study assessed the risk factors of ascending aortic aneurysms and aortic elasticity in children with BAV. The study included 66 patients with no history of transcatheter intervention or surgical procedure who had been diagnosed with isolated BAV. Echocardiographic, blood pressure, and pulse measurements were obtained for all patients. The BAVs were classified as described by Sievers et al. (J Thorac Cardiovasc Surg 133:1226-1233, 2007), and aortic elasticity parameters were calculated using various formulas. The patients were divided into groups with and without cusp fusion, aortic stenosis (AS), aortic regurgitation (AR), or mixed lesions; the groups were then compared. The mean patient age was 10.43 ± 3.91 years; 15%he patients had no AS or AR, 33% had both AS and AR, 17% had AS alone, and 35% had AR alone. The most common type of BAV was type 5, and the ascending aorta z-scores were higher in children with mixed lesions and without a cusp fusion. Aortic distensibility (AD) was significantly higher, and the stiffness index was significantly lower, in patients with an ascending aorta z-score > 4. The ascending aortic z-scores were higher in the no-fusion and mixed lesion (AS + AR) groups, especially those originating from post-stenotic dilation due to AS. The AD was increased in patients with an ascending aorta z-score > 4. Patients should thus be monitored closely for dissection risk, and preventive medical treatment should be started early in those with AS without cusp fusion.

3D segmentation of intervertebral discs: from concept to the fabrication of patient-specific scaffolds

Aim: To develop a methodology for producing patient-specific scaffolds that mimic the annulus fibrosus (AF) of the human intervertebral disc by means of combining MRI and 3D bioprinting. Methods: In order to obtain the AF 3D model from patient's volumetric MRI dataset, the RheumaSCORE segmentation software was used. Polycaprolactone scaffolds with three different internal architectures were fabricated by 3D bioprinting, and characterized by microcomputed tomography. Results: The demonstrated methodology of a geometry reconstruction pipeline enabled us to successfully obtain an accurate AF model and 3D print patient-specific scaffolds with different internal architectures. Conclusion: The results guide us toward patient-specific intervertebral disc tissue engineering as demonstrated by a way of manufacturing personalized scaffolds using patient's MRI data.

Parameters indicative of persistence of valvular pathology at initial diagnosis in acute rheumatic carditis: the role of albumin and CD19 expression

OBJECTIVE

The aim of this study is to define the predictors of chronic carditis in patients with acute rheumatic carditis (ARC).

METHODS

Patients diagnosed with ARC between May 2010 and May 2011 were included in the study. Echocardiography, electrocardiography, lymphocyte subset analysis, acute phase reactants, plasma albumin levels, and antistreptolysin-O (ASO) tests were performed at initial presentation. The echocardiographic assessments were repeated at the sixth month of follow-up. The patients were divided into two groups according to persistence of valvular pathology at 6th month as Group 1 and Group 2, and all clinical and laboratory parameters at admission were compared between two groups of valvular involvement.

RESULTS

During the one-year study period, 22 patients had valvular disease. Seventeen (77.2%) patients showed regression in valvular pathology. An initial mild regurgitation disappeared in eight patients (36.3%). Among seven (31.8%) patients with moderate regurgitation initially, the regurgitation disappeared in three, and four patients improved to mild regurgitation. Two patients with a severe regurgitation initially improved to moderate regurgitation (9.1%). In five (22.8%) patients, the grade of regurgitation [moderate regurgitation in one (4.6%), and severe regurgitation in 4 (18.2%)] remained unchanged. The albumin level was significantly lower at diagnosis in Group 2 (2.6±0.48g/dL). Lymphocyte subset analysis showed a significant decrease in the CD8 percentage and a significant increase in CD19 percentage at diagnosis in Group 2 compared to Group 1.

CONCLUSION

The blood albumin level and the percentage of CD8 and CD19 (+) lymphocytes at diagnosis may help to predict chronic valvular disease risk in patients with acute rheumatic carditis.

Atrial Functions and Aortic Elasticity in Children with Aortic Coarctation

BACKGROUND

Coarctation of the aorta (CoA) is a chronic vascular disease characterized by a persistence of myocardial and vascular alterations. We aimed to evaluate children who have had successful coarctation surgery or balloon dilatation to evaluate the elasticity of the aorta, left atrial ejection force (AEF) and myocardial performance collectively at midterm follow-up.

METHODS

Nineteen patients (7.15 ± 0.9 years of age) and 21 age-sex matched healthy children were included in this study. Left AEF index is defined as the product of mass and acceleration of blood expelled from the left atrium. Aortic stiffness and distensibility were estimated using ascending and descending aorta diameters.

RESULTS

The left atrial force index [(g∙cm/s(2))/m(2)] in the patient group was found to be significantly higher (12.69 ± 7.29, 5.74 ± 2.59, respectively, p = 0.001). Distensibility of the ascending aorta (cm(2)/dynes 10(-6)) was significantly lower in the patient group than in the control group (42.13 ± 24.02, 78.79 ± 20.49, respectively, p < 0.001). The stiffness index of the ascending aorta was significantly higher in the patient group (p < 0.001). We also documented that atrial force index is associated with peak E velocity, right arm systolic blood pressure and left ventricular mass index.

CONCLUSIONS

Our investigation showed that AEF is higher in children who have had successful coarctation surgery or balloon dilatation, and AEF is associated with systolic blood pressure, peak E velocity and left ventricular mass index. Distensibility of the ascending aorta was lower, and stiffness index was higher in children with corrected CoA than in healthy subjects.

KEY WORDS

Atrial ejection force; Balloon dilatation; CoA; Coarctation surgery; Distensibility; Stiffness index.

Association of NFKB1 and NFKBIA polymorphisms in relation to susceptibility of Behçet's disease

Behçet's disease (BD) is a chronic inflammatory autoimmune disease. Although raised levels of proinflammatory cytokines in BD have been reported, the pathogenesis is still unknown. The aim of this study was to investigate the association of NFKB1 and NFKBIA polymorphisms and their single and combined analysis effects on susceptibility of BD in Turkish population. We analysed the distribution of NFKB1 -94 ins/del ATTG (rs28362491) and NFKBIA 3' UTR A→G (rs696) polymorphisms using PCR-RFLP method in 89 patients with BD and 190 controls in this population. Statistical analysis of the results was performed by calculating OR, and 95% CI via χ(2) test and using Bonferroni correction. According to the significant results of both single and combined genotype analysis, the frequencies of ins/ins genotype and ins allele of rs28362491 were significantly higher in patients with BD (Pc = 0.003, 0.004, respectively). Also, higher frequencies of the rs696 variant containing AA genotype was found in patients with BD (Pc = 0.0033), whereas no statistical significant differences in distribution of the alleles of rs696 polymorphism in patients and controls. In addition, according to the combined genotype analysis, the wild type of both rs28362491 and rs696 polymorphisms (ins/ins/AA genotype) was also significantly higher in BD cases (Pc = 0.044). Our findings prove that both single and combined genotype analysis of rs28362491 and rs696 polymorphisms indicate that the wild genotypes of both two SNPs (ins/ins and AA genotypes) and ins/ins/AA combined genotype are strongly associated with enhanced risk of BD in a Turkish population.

Arterial function and anatomy in obese children with cardiovascular risk factors

BACKGROUND

Limited data are available related to the effects of cardiovascular risk factors on abdominal arterial stiffness using carotid and brachial artery indices. Therefore, we aimed to determine arterial changes in obese children and investigate any relation with cardiovascular risk factors.

METHODS

Thirty-eight obese children (mean body mass index: 28.35 ± 4.65 kg/m(2) ) and 34 age- and sex-matched healthy subjects underwent ultrasound measurements of abdominal, carotid and brachial arteries. Aortic strain, pressure strain elastic modulus (Ep), pressure strain normalized by diastolic blood pressure (Ep*), carotid intima-media thickness, carotid artery compliance, brachial artery flow-mediated dilatation, and well-known cardiovascular risk factors were assessed in the obese children.

RESULTS

Obese children had significantly higher Ep and Ep* parameters than the healthy controls (mean: 242.6 [107.1-666.6], 164.2 [110.6-231.5]; P < 0.001, and mean: 3.39 [1.76-7.5], 2.64 [1.46-4.2]; P < 0.001, respectively). Ep and Ep* were significantly correlated with the homeostasis model assessment of insulin resistance (r = 0.587, P = 0.001; r = 0.467, P = 0.004, respectively). Receiver-operator curve analysis of Ep for identification of children with cardiovascular risk factors showed that the area under the curve for hyperinsulinemia was 0.80 (P < 0.001) and for hypertriglyceridemia was 0.62 (P < 0.01).

CONCLUSIONS

Abdominal arterial stiffness parameters as well as carotid intima-media thickness and brachial arterial flow-mediated dilatation assessment were similarly useful in identifying obese children with cardiovascular risk factors. Insulin resistance is related with the augmented rigidity of the aortic wall in obese children.

Complications of cardiac catheterization in pediatric patients: a single center experience

We analyzed 519 catheterization procedures performed over a period of two years retrospectively. Several risk factors related to the patient or catheterization were analyzed. The incidence of complications was 6.2%. The most common major and minor complications were arterial thrombosis that required intervention and transient arrhythmias, respectively. The incidence of complications during interventional studies was higher (9.7%) when compared to that in diagnostic procedures (5.4%). The independent risk of any complication was greatest up to 1 year of age (p = 0.02). The risks of a major complication (p = 0.003) and development of arterial thrombosis (p = 0.02) were significantly greater in patients <1 year of age by univariate analysis. The risks of pediatric cardiac catheterization continue to decline. The complication rates associated with interventional catheterization were significantly higher than with diagnostic catheterization in this study. Younger age, particularly <1 year of age, is the strongest predictor of development of any complication.

Infracardiac total anomalous pulmonary venous drainage with unusual presentation

Total anomalous pulmonary venous drainage (TAPVD) is a rare entity which forms approximately 0.4 to 2% of all congenital heart disease. The infracardiac type usually involve obstructions on pulmonary venous connections and comprising a quarter of all TAPVD cases. The clinical findings in patients with obstructed infracardiac TAPVD could mimic respiratuary distress of several different etiologies during first hours of life. In this article, we present a case of a neonate with infracardiac type of TAPVD presented with only distinct subcutaneous veins of abdominal and thoracic wall.

[Evaluation of unresponsiveness to standard high-dose gamma globulin therapy in Kawasaki disease]

OBJECTIVES

We investigated the incidence of unresponsiveness to intravenous gamma globulin (IVIG) treatment in Kawasaki disease (KD) and evaluated its relation with coronary artery involvement.

STUDY DESIGN

The study included 20 children (13 boys, 7 girls; mean age 4.2+/-3.4 years; range 9 months to 12 years) with KD. The mean disease duration on admission was 7.3+/-2.4 days (range 5 to 14 days). Initial treatment consisted of a single dose of IVIG and high-dose of aspirin. Unresponsiveness was defined as the persistence of fever and other symptoms within the first 48 hours of treatment. All the patients were evaluated by two-dimensional echocardiography before and after treatment. The mean follow-up period was 16.5+/-2.8 months (range 9 to 24 months).

RESULTS

Unresponsiveness was seen in five patients (25%), who received a subsequent dose of IVIG, which improved fever in two patients. The remaining three patients received high-dose methylprednisolone. One patient who showed no response to either IVIG or methylprednisolone was treated with low-dose oral methotrexate. Six patients (30%) had coronary artery involvement (4 dilatations, 2 aneurysms), five patients on admission echocardiography, and one patient on control echocardiography seven days after treatment. Of five unresponsive patients, four (80%) had coronary artery involvement on admission. Patients with coronary involvement underwent coronary angiography after a mean of one year. Five patients had normal coronary arteries, whereas no angiographic regression was observed in one patient who had a giant coronary artery aneurysm on admission and was treated with oral methotrexate.

CONCLUSION

The incidence of unresponsiveness to treatment was markedly high in KD patients who had coronary artery involvement on admission.