Clinical Impact of Cardiovascular Magnetic Resonance in Cancer Patients With Suspected Cardiomyopathy.

Objectives: To assess the clinical impact of Cardiovascular Magnetic Resonance (CMR) in clinical decision making of cancer patients with a suspected cardiomyopathy in a tertiary cancer center. Background: Cardiomyopathies of diverse etiologies are frequently encountered in a Cardio-Oncology practice. The clinical impact of CMR after a presumptive diagnosis of cardiomyopathy has not been studied in cancer patients. Methods: We reviewed data on cancer patients with presumptive diagnosis of cardiomyopathy who underwent CMR in a tertiary cancer center. The clinical impact of CMR was defined as either change in clinical diagnosis or management post CMR results. Univariate and multivariate logistic regression models were used to assess whether any of the baseline characteristics were predictive of the clinical impact of CMR. Results: A total of 110 consecutive patients were identified. Clinical impact of CMR was seen in 68 (62%) patients. Change in the clinical diagnosis and management was seen in 56 (51%) and 41 (37%) of patients, respectively. The most common change was prevention of endomyocardial biopsy in 26 patients (24%). Overall, patients with higher left ventricular ejection fraction (LVEF) by echocardiography (echo), clinical impact was influenced more by CMR (LVEF of 37.2 ± 12.3% vs. 51.5 ± 11.6%, p < 0.001). Cancer diagnosis of multiple myeloma was associated with change in the management post CMR (adjusted OR of 25.6, 95% CI 4.0-162.4, p = 0.001). Suspicion of infiltrative cardiomyopathy was associated with a higher likelihood of change in diagnosis. Having an LVEF≥40 by echo was associated with change in diagnosis and management by CMR. Conclusions: Utilization of CMR has a significant clinical impact in cancer patients with suspected cardiomyopathy. Patients with cancer diagnosis of multiple myeloma, suspicion of infiltrative cardiomyopathy and those with higher LVEF by echo seem to benefit more from CMR.

Maternal ß-hemolytic streptococcal pharyngeal exposure and colonization in pregnancy.

OBJECTIVES: To report the pharyngeal colonization rate of ß-hemolytic streptococci and changes in the value of antistreptolysin O (ASO) and anti-DNase B serology titers during pregnancy. METHODS: Healthy pregnant women were recruited and blood was drawn in each trimester. The upper limit of normal (ULN) values for ASO and anti-DNase B was calculated for each trimester. Throat swabs were collected for culture and positive cultures were further assessed for the identification of serogroup of the isolated ß-hemolytic streptococcus. RESULTS: Out of a total of 126 pregnant women, 34.1% had positive throat cultures. Group C and group G strains were isolated in 18.2% of throat cultures while group F was detected in 13.5% of cases. The rate of colonization with GAS was 1.6%. There was an overall drop in ASO titer during pregnancy while anti-DNase B titers remained relatively unchanged. ULN values of 164(IU), 157(IU), and 156(IU) were calculated for ASO at the first, second, and third trimesters, respectively. Based on the ULN values, 28.6% of patients had recent streptococcal exposure. CONCLUSIONS: These results show that pregnant women act as a reservoir for spreading potentially immunogenic (groups C and G) and disease producing (group F) virulent strains of streptococci.

Defining the best practice patterns for the neonatal systemic-to-pulmonary artery shunt procedure.

OBJECTIVES: To assess variation in outcome measures and their associations with shunt thrombosis prophylaxis regimens after systemic-to-pulmonary artery shunt surgery across centers in the United States participating in the Pediatric Health Information System database. METHODS: We reviewed data on neonates who underwent an off-pump shunt procedure at 39 centers between 2000 and 2011. The overall variation in rates of discharge mortality and shunt-related complications were assessed by funnel plots. Complications were defined as revision/repeat of the shunt procedure during the same admission, institution of extracorporeal membrane oxygenation after surgery, and catheter interventions after shunt surgery. Bayesian hierarchical modeling was used to identify outliers. Shunt thrombosis prophylaxis regimens including the time of initiation of aspirin were compared between high and low outliers. RESULTS: A total of 2058 index operations were identified. Funnel plots highlighting the outcomes from various centers allowed discrimination of discharge mortality and complication rates around an aggregate of 6.7% and 12.3%, respectively. Bayesian modeling showed the presence of substantial variation in complication rates between centers; 20% of them were identified as outliers. Aspirin was initiated significantly earlier during the hospital course in centers with a lower composite rate of complications than those with higher rates (median initiation day of 2 [interquartile range (IQR), 1-3] in low outliers vs 4 [IQR, 3-6] in high outliers; P < .001). CONCLUSIONS: A substantial variation was found between hospitals in the rate of shunt-related complications. Centers with best outcomes implement aspirin earlier in their postoperative shunt thrombosis prophylaxis regimen.

Spondylodiscitis: a rare complication of button battery ingestion in a 10-month-old boy.

Nowadays, button battery ingestion accounts for one of the common foreign body ingestions among pediatric population. Unexpected manifestations in this setting, particularly after late removal, are confusing and might be misleading and postpone the proper management. We report a case of button battery ingestion in a 10-month-old boy who was primarily considered uncomplicated. However, he was readmitted with neck stiffness, which later turned to be due to spondylodiscitis. Based on this report, we strongly recommend considering spondylodiscitis as a late but serious complication of button battery ingestion in any patient who presents with restricted neck movement following foreign body ingestion.

The impact of preload alteration on the myocardial performance index through implementing positive end expiratory pressure.

Load independent methods should be used for the assessment of ventricular function. Debate still exists regarding whether tissue Doppler imaging (TDI) indices are influenced by preload. Here, we evaluated the effect of positive end expiratory pressure (PEEP) related preload reduction on both conventional pulsed Doppler (PD) and TDI myocardial performance index (MPI). Thirty-eight mechanically ventilated patients of 3 months to 12 years old (mean ± SD age of 30 ± 11 months) without overt heart disease were enrolled. Doppler mitral inflow velocities, isovolumetric contraction and relaxation times and aortic ejection time in addition to TDI peak systolic, early and late diastolic velocities from the basal segment of left ventricular lateral wall were determined for each patient before and after applying high PEEP (10 cmH(2) O).PD-MPI was load dependent (0.61 ± 0.22 vs. 0.78 ± 0.25, P = 0.002). However, TDI-MPI did not significantly change after the use of high PEEP declining the left ventricular volume loading (0.78 ± 0.21 vs. 0.84 ± 0.22, P = 0.23). Hence, regarding various interfering pathophysiologic factors particularly preload reduction, it seems that TDI-MPI would be a more reliable index for the assessment of ventricular function.

Assessment of left atrial ejection force in mildly asphyxiated newborns.

OBJECTIVE: Asphyxia-induced cardiac insult is one of the major causes of mortality and morbidity in the course of perinatal asphyxia. Nowadays, a remarkable trend of interest is sensed introducing a plausible modality for early detection of cardiac insults at the beginning stages of asphyxia. In this study we aimed to evaluate diagnostic utility of transmitral Doppler-derived parameters as well as left atrial ejection force index as a marker of left atrial contractile function in these patients. METHODS: In a prospective study selected cases of 26 asphyxiated newborns with preserved systolic function underwent conventional transmitral Doppler flow echocardiographic assessment. Left atrial ejection force index was further calculated for all patients. Data was compared with normal ranges of healthy newborns in order to clarify the diagnostic utility of these parameters for determining minor cardiac insults in this age group. FINDINGS: We found that mildly asphyxiated newborns showed an increase in the values of left atrial ejection force index (5.44±2.12 kilodyne vs. 6.66±2.17 kilodyne, P= 0.02) and left atrial filling fraction (39%±10% vs. 45%±8%, P= 0.01). Furthermore, the acceleration and deceleration rate of early filling flow peak velocity were decreased in this group of asphyxiated newborns. CONCLUSION: Assessment of left atrial ejection force in mildly asphyxiated newborns reveals that newborns with even mild asphyxia, although could not be categorized in conventional grading system, suffer to some extent from a ventricular filling abnormality. This type of latent ventricular filling abnormality could simply be unmasked by calculation of atrial ejection force index.

Upper endoscopic findings in children with recurrent abdominal pain: high prevalence of hiatus hernia.

OBJECTIVE: Recurrent abdominal pain (RAP) by itself is one of the common reasons in child-aged patients to refer to a clinician. Some of these patients are presented with more serious features, so-called the "red flag". The most important issue in management of RAP is to distinguish the type of it, whether it is functional or organic. In this study we aimed to assess the redundancy of red-flagged RAP with findings of esophago-gastro-deudonoscopy. METHODS: In a 2 year prospective study 150 consecutive children with RAP who showed red flags underwent esophago-gastro-deudonoscopy. The prevalence of each finding was recorded. Overall positive predictive value of predicting an endoscopic finding while having a red-flag was calculated. FINDINGS: Among all the patients, 126 cases showed at least a positive finding in their endoscopy that corresponded to the positive predictive value of 84% for predicting the presence of an endoscopic finding according to red flags. Interestingly, 20% of patients showed hiatus hernia when surveyed. CONCLUSION: Comprehensive physical examination is needed to avoid performing esophago-gastro-deudonoscopy without indication in patients with recurrent abdominal pain.

Augmentation of left atrial contractile function: a herald of iron overload in patients with beta thalassemia major.

Early detection of myocardial iron overload is crucial for optimal management of patients with beta thalassemia major, which could lead to intensification of iron chelating therapy. In this study, we evaluate the conventional echocardiography and tissue Doppler imaging measurements in patients with beta thalassemia major and further introduce the assessment of atrial ejection force as a feasible price-saving approach for early detection of myocardial iron overload. During a 1-year period, 42 cases of beta thalassemia major aged <21 years and with preserved systolic function were evaluated with magnetic resonance T2* imaging (MRI T2*), conventional echocardiography, and tissue Doppler imaging techniques. Patients were classified into two groups according to their myocardial MRI T2* values, with and without critical iron loading. All patients with echocardiographic evidence of moderate and severe stages of diastolic dysfunction showed critical iron loading in their MRI T2*. After excluding those patients with severe and moderate ventricular diastolic filling abnormality, the atrial ejection force index (P = 0.002) and a number of volume indexes of the left atrium showed a significant difference between the two groups. None of the tissue Doppler imaging measurements showed a statistically significant difference between the two groups. The atrial ejection force index of 7.41, with a sensitivity of 93% and a specificity of 74%, was suggested to detect critical cardiac iron loading. These results imply that combining the atrial ejection force index with the transmitral-derived echocardiographic assessment is a feasible way to detect early stages of myocardial iron overload in patients with beta thalassemia major.

Clinical spectrum of 15 patients with HIV-related ocular involvement in Tehran.

AIM: To determine the frequency of HIV-related ocular involvement and to describe the characteristics of involvement in a special clinic in Tehran. METHODS: In this cross sectional study, 141 patients (125 male and 16 female, 282 eyes) of HIV-infected patients with various stages of HIV infection that were referred to Center of behavioral diseases were evaluated during a period of 7 months. Every patient had a complete profile including demographic data, method of HIV transmission, recent CD4 T cell lymphocyte count, serological studies for common sexual or blood-born viruses and toxoplasmosis, history of antiretroviral therapy, and associated systemic disease. RESULTS: A total of 141 patients were evaluated. HIV-related ocular involvement was detected in 15 patients (10.6%), including 3 mycobacterium tuberculosis-related choroiditis, 2 cytomegalovirus retinitis, 2 retinal toxoplasmosis, 2 herpes simplex virus-related lesions, 1 HIV-associated retinopathy, 1 herpes zoster ophthalmicus, 1 undetermined vitritis, and 3 cases of cranial nerve involvement including 2 cases of gaze palsy and 1 case of papilitis. In our study, mean CD4 T cell lymphocyte count was fewer in patients with ocular involvement than in patients without ocular involvement (204.7±123.8 vs 403.7±339.7, P=0.029), but there was no difference in other possible associated factors between two groups. CONCLUSION: Mycobacterium tuberculosis-related choroiditis and neurophthalmic lesions are the most common HIV-related ocular involvements in Tehran that is different from those of recent publications in developed countries.

N-terminal pro-B-type natriuretic peptide and ventricular dysfunction in children and adolescents.

Our aim was further to clarify the diagnostic usefulness of N-terminal pro-B-type natriuretic peptide for detecting ventricular dysfunction in children, and its correlation with myocardial performance index and New York University Pediatric Heart Failure Index score. We also hypothesized that the level of this natriuretic peptide in the serum could predict the severity of diastolic abnormalities in children with cardiac failure. We enrolled 99 patients, aged from 3 months to 16 years, who had been referred for echocardiography to evaluate ventricular function. Echocardiographic evidence of left ventricular systolic and diastolic dysfunction was found in 20 and 42 patients, respectively. We classified these patients as having impaired relaxation, seen in 12 patients, pseudonormal patterns seen in 19 patients, and restrictive-like patterns of filling seen in 11 patients. The mean of the log-transformed values for N-terminal pro-B-type natriuretic peptide increased significantly according to the severity of diastolic dysfunction (p = 0.003, p = 0.022, p < 0.0001). A value of 178 pg/ml had a sensitivity of 88% and specificity of 81% for detecting abnormal diastolic function (p < 0.0001). Furthermore, the log-transformed values correlated with myocardial performance index (p < 0.0001) in a positive manner, and the levels increased significantly according to New York University Pediatric Heart Failure Index score, showing a linear correlation with a robust r value for regression (r = 0.89, p < 0.0001). Our findings suggest that higher levels of the peptide, having a good correlation with New York University Pediatric Heart Failure Index score and myocardial performance index, might be a suitable marker to rule out ventricular diastolic dysfunction in children.

Coenzyme Q10 improves diastolic function in children with idiopathic dilated cardiomyopathy.

We aimed to determine the effect of supplementation with coenzyme Q10 on conventional therapy of children with cardiac failure due to idiopathic dilated cardiomyopathy. In a prospective, randomized, double-blinded, placebo-controlled trial, we randomized 38 patients younger than 18 years with idiopathic dilated cardiomyopathy to receive either coenzyme Q10, chosen for 17 patients, or placebo, administered in the remaining 21. Echocardiographic systolic and diastolic function parameters were determined for every patient at baseline, and after 6 months of supplementation. The index score for cardiac failure in children as established in New York was used for assessing the functional class of the patients. After 6 months supplementation, 10 patients randomized to receive coenzyme Q10 showed improvements in the grading of diastolic function, this being significantly more than that achieved by those randomized to the placebo group (p value = 0.011). The mean score for the index of cardiac failure index for those receiving coenzyme Q10 was also lower than the control group (p value = 0.024).Our results, therefore, indicate that administration of coenzyme Q10 is useful in ameliorating cardiac failure in patients with idiopathic dilated cardiomyopathy through its significant effect on improving diastolic function.