Weight gain in infants with congenital heart disease; breastfeeding alone versus supplemental spoon-feeding of expressed breast milk: an open-label, pilot, randomised control trial.

OBJECTIVES: Infants with congenital heart disease and increased pulmonary blood flow frequently suffer from feeding difficulties and growth failure. Providing expressed breast milk by spoon has been hypothesised to decrease energy expenditure in these infants as compared to breastfeeding. This study assessed the effect of supplemental feeding of expressed breast milk on weight gain in infants with unoperated congenital heart disease. METHOD: This was a prospective open-label randomised control trial. In total, 50 infants with post tricuspid left to right shunt were enrolled in the study. In the intervention group, apart from breastfeeding, a minimum predetermined volume of expressed breast milk was targeted to be given by spoon. 30-50 kcal/kg/day was given by expressed breast milk by spoon-feeding. In the control group, the infants were given at least 8 feeds per 24 hours by direct breastfeeding. Both groups were followed up for 1 month and assessed for weight gain. RESULT: Despite a high rate of protocol breach in both groups (30% overall), infants in the intervention group had better weight gain at one-month follow-up compared to those in the control group, 780 ± 300 versus 530 ± 250 gm (p = 0.01). CONCLUSION: In infants with left to right shunts, supplemental feeding of expressed breast milk by spoon along with breastfeeding resulted in significantly higher average weight gain at 30 days compared to the control group who received breastfeeding alone. Future studies with larger sample sizes and longer follow-ups need to be done to confirm the findings of this study.

The World Health Organization Measles Programmatic Risk Assessment Tool-Pilot Testing in India, 2014.

Measles is a leading cause of child mortality, and reduction of child mortality is a key Millennium Development Goal. In 2014, the World Health Organization and the U.S. Centers for Disease Control and Prevention developed a measles programmatic risk assessment tool to support country measles elimination efforts. The tool was pilot tested in the State of Uttarakhand in August 2014 to assess its utility in India. The tool assessed measles risk for the 13 districts of Uttarakhand as a function of indicator scores in four categories: population immunity, surveillance quality, program delivery performance, and threat. The highest potential overall score was 100. Scores from each category were totaled to assign an overall risk score for each district. From this risk score, districts were categorized as low, medium, high, or very high risk. Of the 13 districts in Uttarakhand in 2014, the tool classified one district (Haridwar) as very high risk and three districts (Almora, Champawat, and Pauri Garhwal) as high risk. The measles risk in these four districts was largely due to low population immunity from high MCV1-MCV2 drop-out rates, low MCV1 and MCV2 coverage, and the lack of a supplementary immunization activity (SIA) within the past three years. This tool can be used to support measles elimination in India by identifying districts that might be at risk for measles outbreaks, and to guide risk mitigation efforts, including strengthening routine immunization services and implementing SIAs.

Factors Associated With Hypertension and Cardiovascular Parameters in Children With Infrequently Relapsing Nephrotic Syndrome.

OBJECTIVES: To assess the prevalence of hypertension in children with infrequently relapsing nephrotic syndrome (IRNS) and its association with dyslipidemia, and end organ damage including left ventricular hypertrophy (LVH), at relapse and after steroid induced remission. METHODS: Prospective observational study conducted in 83 children aged 1-12 years with IRNS, presenting in relapse. Blood pressure, fundus examination, blood and urine investigations were done at relapse and then at 4 weeks of therapy. Echocardiography at 4 weeks was performed for assessment of LVH and relative wall thickness (RWT) for concentric geo-metry (CG). RESULTS: 27 patients (32.5%) developed hypertension, out of which 21 patients (25.3%) had stage I hypertension. Hypertension in first episode (63.0%, P<0.01) and in previous relapses (87.5%, P<0.001) was significantly associated with hypertension in the current episode. 12 patients had a positive family history of hypertension, of which 8 (66.7%) were classified under the hypertensive group (P=0.016). Concentric geometry (CG) was found in 28% of hypertensive and 5.5% of non-hypertensive children (P=0.011). On regression analysis, a lower Up:Uc at the time of relapse was found to have a protective role for development of hypertension. CONCLUSION: One third children with IRNS had hypertension at relapse and a high proportion of hypertensive patients had CG pattern on echocardiography.

Association of HLA class II DR/DQ alleles in children and adolescents with rheumatic heart disease from a tertiary care centre in North India.

INTRODUCTION: Rheumatic fever and RHD constitutes an important public health problem in India. The relatively low attack rate of RF, the high concordance rate for RF in monozygotic twins (19%) compared to dizygotic twins (2.5%), and the high familial incidence of RF suggest the involvement of host genetic factors in susceptibility to RF with consequential progression to RHD. OBJECTIVE: To study the association of HLA CLASS II DR/DQ alleles in children and adolescents with RHD from a tertiary care center in North India. METHODS: 30 RHD patients and 30 age and sex-matched controls were included in our study and blood samples for HLA typing were processed through LAB Type™ reverse SSO DNA typing method. The assignment of the HLA typing was based on a comparison with already published HLA gene sequences. RESULTS: The mean age of RHD patients and matched control groups were 12.97 ± 2.95 and 11.93 ± 3.23, respectively. In the cases and control group, males accounted for 63.3% and 50% of the patients respectively. A significant difference was found between the cases and controls for HLA DR∗ 15 (p-value 0.002), HLA DR∗ B4 (p-value 0.045), HLA DR∗ B5 (p-value 0.017), and HLA DQB1∗ 02 (p-value 0.005). CONCLUSION: Our study suggests that HLA class II haplotypes may provide insight into the molecular mechanism of RHD and be a useful tool in predicting the clinical outcome in RF patients, thereby affording new means of intervention or vaccine design. Larger studies are needed to address this in our population.

Estimation of pulmonary vascular resistance: correlation between echocardiography and catheterization data in patients with congenital heart disease.

BACKGROUND: The ratio of peak tricuspid regurgitation velocity (TRV) and right ventricular outflow time-velocity integral (TVI RVOT) has been described as a good correlate of pulmonary vascular resistance (PVR). However, this method has not been well studied in congenital heart disease. METHOD: Twenty patients with post-tricuspid shunt lesions who were planned to undergo cardiac catheterization were enrolled for the study. The ratio of TRV/TVI(RVOT) was measured via transthoracic echocardiography and correlated with invasively derived PVR (PVR(CATH)). PVR(CATH) was measured by cardiac catheterization. Fick's principle was used to calculate the pulmonary blood flow and oxygen consumption was assumed. Linear regression analysis was done to find the correlation between TRV/TVI(RVOT) and PVR(CATH). RESULTS: There was a significant correlation between the two variables, r = 0.635(P = 0.003). Subgroup analysis revealed that this correlation was better at lower values of PVR(CATH) (r = 0.817 for PVR < 6 Wood units (WU)) than higher values (r = 0.659 for PVR > 6 WU). TRV/TVI(RVOT) ratio of greater than 0.145 predicted with 80% sensitivity and specificity a PVR > 6 WU. CONCLUSIONS: There is modest correlation between TRV/TVI(RVOT) ratio and invasively derived PVR in congenital shunt lesions, especially in PVR < 6 WU. TRV/TVI(RVOT) ratio could be useful in identifying patients with congenital shunts whose PVR is likely to be <6 WU, and hence, do not need cardiac catheterization.

Revisiting Folger's pouch in double-chambered right ventricle.

Folger's pouch is a right ventricular outflow pouch arising from the distal low-pressure chamber in double-chambered right ventricle. It is rarely described on echocardiogram due to difficult visualization and lack of knowledge of its existence. Retrospective assessment of echocardiogram after an angiocardiographic evaluation demonstrates the pouch in a modified high parasternal view.

Comparison of antistreptolysin O and anti-deoxyribonucleic B titers in healthy children to those with acute pharyngitis, acute rheumatic fever, and rheumatic heart disease aged 5-15 years.

BACKGROUND: Acute rheumatic fever (ARF) affects millions of children in the third world countries like India. The diagnosis of rheumatic fever is based on the Jones criteria with serological titers, antistreptolysin O titer (ASO), and anti-deoxyribonucleic B (ADB), taken as evidence of recent streptococci infection. There is a lack of recent data available on ASO and ADB titers in children from the Delhi/NCR and thus adequate geographical area-specific cutoffs for the region are not available. AIMS AND OBJECTIVES: The aim of this study is to determine and compare the ASO and ADB antibody titers in children with acute pharyngitis, ARF, rheumatic heart disease (RHD), and in healthy children of the Delhi/NCR region. MATERIALS AND METHODS: Twenty-six cases of ARF, 51 cases of RHD, 50 cases of acute pharyngitis, and 84 healthy normal children were included in the study. A single ASO and ADB titer measurement was done in these children. RESULTS: The ASO titers was raised in acute pharyngitis - 303 IU/ml (interquartile range [IQR], 142-520 IU/ml) and ARF - 347.5 IU/ml (IQR, 125-686 IU/ml) children in comparison to healthy controls - 163.5 IU/ml (IQR, 133-246.5 IU/ml) and RHD patients - 163 IU/ml (IQR, 98.250-324.500). The ADB titers were highest in ARF patients - 570.5 IU/ml (IQR, 276-922 IU/ml) followed with RHD - 205 IU/ml (IQR, 113.6-456.5), healthy controls - 78.25 IU/ml (IQR, 53.39-128.15 IU/ml), and acute pharyngitis - 75.12 IU/ml (IQR, 64.5-136 IU/ml). The upper limit of normal (ULN) values of ASO and ADB computed from normal healthy children were 262.4 IU/ml and 134.44 IU/ml, respectively, and these can be used as cutoff values for recent streptococcal infection in this geographical area. CONCLUSIONS: The median ASO titers in acute pharyngitis group and ARF were significantly raised compared to that of the control group. The ADB titers were raised in ARF and RHD patients albeit the levels were higher in ARF patients. The derived ULN values can be used as cutoff reference.

Bilateral Spontaneous Urinoma in a Cyanotic Child.

BACKGROUND: Urinoma is an encapsulated collection of extravasated urine, secondary to trauma or obstructive uropathy. Spontaneous bilateral urinoma is rare. CASE CHARACTERISTICS: 7-year-old boy with cyanotic heart disease and fever of unknown origin. OBESERVATION: The ultrasound abdomen and CT abdomen revealed bilateral spontaneous urinoma which was aspirated and was found to be infected. Following intravenous atibiotics the child became afebrile, with subsequent renal scans showing no recurrence. MESSAGE: Hypoxia and consequent polycythemia may be responsible for perinephric leaks leading to Non-traumatic spontaneous urinoma.

Total anomalous pulmonary venous connection masking an aortopulmonary window: A rare combination of defects.

The association of aortopulmonary (AP) window with total anomalous pulmonary venous connection (TAPVC) has so far not been reported. We report a unique case of an 8-month-old child who presented with congestive cardiac failure and severe pulmonary arterial hypertension. Initial echocardiography revealed supracardiac TAPVC. Cardiac computed tomography showed the presence of Type I AP window along with the TAPVC. In the presence of severe pulmonary hypertension and dilated right ventricle, AP window may easily be missed if not actively looked for.

Twiddler's syndrome in a patient with CRT-D device - A case report.

Twiddler's syndrome is a rare cause of pacemaker lead dislodgement. A 61-year-old female patient was implanted with a defibrillator capable of cardiac re-synchronization therapy (CRT-D); 10 months later, she presented with uneasiness and vibratory sensations in the chest. Fluoroscopy revealed rotation of the pulse generator along its longitudinal axis and dislodgement of all three leads. Diagnosis of Twiddler's syndrome was made.

Recurrent chest pain after treatment of spontaneous coronary artery dissection: An enigma.

Spontaneous coronary artery dissection (SCAD) is a rare entity. It has been described in various settings like pregnancy, collagen vascular diseases, cocaine abuse, heavy exercise, variant angina, eosinophilic arteritis, or fibro muscular dysplasia. It is also easy to miss a dissection during angiography, as the typical radiolucent lumen seen in coronary angiography may be absent in many cases. In this report, we describe the case of a 35-year-old female who presented with acute ST elevation myocardial infarction due to spontaneous coronary dissection. She had been having episodic chest pain for one year and had been seen by two different cardiologists but was thought to have non-cardiac symptoms. Even during the index hospitalization, she underwent coronary angiography three times before coronary dissection could be identified as the cause of her symptoms. She underwent coronary artery bypass graft surgery uneventfully. However, even after myocardial revascularization, she has had multiple episodes of chest pain requiring hospitalization. However, we have not been able to find a specific cause for it and the cause of her recurrent chest pain remains an enigma. This case highlights the problems, which arise while managing a case of SCAD. More research is needed to find the exact etiology and long-term prognosis of this condition.