Neurodevelopmental outcomes of healthy Chinese term infants fed infant formula enriched in bovine milk fat globule membrane for 12 months - A randomized controlled trial.

BACKGROUND AND OBJECTIVES: Human milk fat globule membrane (MFGM) has multifunctional health benefits. We evaluated neurodevelopment and growth of healthy term infants fed bovine milk-derived MFGM-enriched formula (MF) over 12 months. METHODS AND STUDY DESIGN: A prospective, multi-center, double-blind, randomized trial was conducted in Fuzhou, China. Healthy term infants (n=212), aged <14 days, were assigned randomly to be fed MF or a standard formula (SF) for 6 months and then switched to stage 2 MF and SF formula until 12 months. A reference group (n=206) contained healthy breastfed infants (BFR). Neurodevelopment was assessed with Bayley-III Scales. RESULTS: At 12 months, the composite social emotional (+3.5) and general adaptive behaviour (+5.62) scores were significantly higher in MF than SF (95% CIs 0.03 to 6.79 and 1.78 to 9.38; p=0.048 and 0.004, respectively). Mean cognitive (+2.86, 95% CIs -1.10 to 6.80, p=0.08), language (+0.39, 95% CIs -2.53 to 3.30, p=0.87) and motor (+0.90, 95% CIs -2.32 to 4.13, p=0.49) scores tended to be higher in MF than SF, but the differences between the two groups were not significant. BFR scored higher on Bayley-III than either MF or SF at 6 and 12 months. Cognitive scores were significantly higher in BFR than SF (95% CI 0.05 to 7.20; p=0.045), but not MF (p=0.74) at 6 months. Short-term memory was significantly higher in MF than SF at 12 months (95% CI 1.40 to 12.33; p=0.002). At 4 months, serum gangliosides were significantly higher in MF and BFR than SF (95% CI 0.64 to 13.02; p=0.025). Milk intake, linear growth, body mass and head circumference were not significantly different between formula-fed groups. CONCLUSIONS: MFGM supplementation in early life supports adequate growth, increased serum gangliosides concentration and improves some measures of cognitive development in Chinese infants.

Diagnosis of double-chambered left ventricle using echocardiography.

Double-chambered left ventricle (DCLV) is a particularly rare congenital cardiovascular malformation that is difficult to diagnose. It is characterized by the subdivision of the left ventricle into two chambers by an abnormal septum or muscle band. Here, we report 12 patients with DCLV. Differential diagnoses of DCLV include four other cardiac diseases, diverticulum, aneurysm, hypertrophic cardiomyopathy, and left ventricular noncompaction. Echocardiography plays an important role in the diagnosis of this rare condition and in differentiating it from other diseases.

Left atrial appendage aneurysm in pediatrics.

Left atrial appendage aneurysm (LAAA) is a rare cardiac anomaly with potentially life-threatening complications of atrial tachyarrhythmias and systemic thromboembolism. It is often diagnosed incidentally and rarely during childhood. Echocardiography is considered the primary method of LAAA diagnosis; in particular, the subxiphoid view is more useful in pediatrics. Surgical intervention and drug management are recommended to prevent potentially lethal complications. Herein, we report five cases of patients with LAAA during infancy and childhood, caused by both congenital and acquired conditions. One patient underwent surgical resection through left lateral thoracotomy without cardiopulmonary bypass and another patient underwent drug management.

Application of an Infection Control Protocol (ICP) Reduced Cardiac Device Infection (CDI) in Low-Volume Centers.

BACKGROUND Cardiac device infection (CDI) is a serious complication of cardiovascular implantable electronic device (CIED) implantations. Many risk factors have been identified, but several are still uncertain. This study aimed to identify and evaluate the risk factors. Moreover, an infection control protocol (ICP) was carried out, and its efficacy in reducing CDIs was investigated. MATERIAL AND METHODS A total of 1259 patients who received permanent pacemaker (PPM) implantations were enrolled in this study in a 3-year period in a high-volume center and low-volume centers in the central area of Shaanxi Province, China. Follow-up data of all enrolled patients were collected. The risk factors for CDIs were identified and analyzed. The ICP was adopted in the low-volume centers. Data, including CDI rates, medical costs, and microbiology, were collected and compared. RESULTS Male gender, diabetes, CKD, operation duration, PPM replacement, and low center volume were identified as the risk factors for CDIs. Furthermore, CDI rates in low-volume centers were significantly higher than in high-volume centers. The adoption of an ICP dramatically reduced CDI rates in low-volume centers without significant increases in medical costs. CONCLUSIONS ICPs were easily carried out, effective, and economical in controlling CDIs in low-volume centers, which was identified as a risk factor of CDIs.

Anomalous origin of the left coronary artery from the pulmonary artery in infants: imaging findings and clinical implications of cardiac computed tomography.

PURPOSE: This study aimed to retrospectively analyze the imaging features of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in pediatric patients, with cardiac computed tomography (CT) and echocardiography. MATERIALS AND METHODS: To define the precise location of ostium of the left coronary artery, we examined 9 patients using chest film, electrocardiogram, echocardiography, and cardiac CT 4 modalities, 2 of them also using cardiac MR and 1 of them using catheter cardiac angiography. Cardiac CT scan was performed in all 9 patients using a body size adapted low-dose protocol after bolus injection of intravenous nonionic contrast medium. Multiplane reconstruction, maximum intensity projection, and 3-dimensional coronary tree images were obtained for each patient. Two radiologists in consensus analyzed the cardiac CT findings for the origin of the anomalous coronary artery, course, and collateral vessels. The ALCAPA in these 9 patients was confirmed retrospectively by surgery. RESULTS: Cardiac CT can distinguish the site of origin of the anomalous left coronary artery and variants: 2 patients with inner ostium of the pulmonary trunk, 3 patients with left-sided ostium, 2 patients with posterior ostium, and 2 patients with sinus of the pulmonary root ostium; 1 patient combined with the right coronary artery arising from the left coronary sinus. CONCLUSIONS: Cardiac CT can provide fast and accurate depiction of complex coronary arteries, particularly in unstable and fragile patients with ALCAPA, and according to cardiac CT, surgical strategies can be decided.

Development and Validation of a Deep-Learning Network for Detecting Congenital Heart Disease from Multi-View Multi-Modal Transthoracic Echocardiograms.

Early detection and treatment of congenital heart disease (CHD) can significantly improve the prognosis of children. However, inexperienced sonographers often face difficulties in recognizing CHD through transthoracic echocardiogram (TTE) images. In this study, 2-dimensional (2D) and Doppler TTEs of children collected from 2 clinical groups from Beijing Children's Hospital between 2018 and 2022 were analyzed, including views of apical 4 chamber, subxiphoid long-axis view of 2 atria, parasternal long-axis view of the left ventricle, parasternal short-axis view of aorta, and suprasternal long-axis view. A deep learning (DL) framework was developed to identify cardiac views, integrate information from various views and modalities, visualize the high-risk region, and predict the probability of the subject being normal or having an atrial septal defect (ASD) or a ventricular septaldefect (VSD). A total of 1,932 children (1,255 healthy controls, 292 ASDs, and 385 VSDs) were collected from 2 clinical groups. For view classification, the DL model reached a mean [SD] accuracy of 0.989 [0.001]. For CHD screening, the model using both 2D and Doppler TTEs with 5 views achieved a mean [SD] area under the receiver operating characteristic curve (AUC) of 0.996 [0.000] and an accuracy of 0.994 [0.002] for within-center evaluation while reaching a mean [SD] AUC of 0.990 [0.003] and an accuracy of 0.993 [0.001] for cross-center test set. For the classification of healthy, ASD, and VSD, the model reached the mean [SD] accuracy of 0.991 [0.002] and 0.986 [0.001] for within- and cross-center evaluation, respectively. The DL models aggregating TTEs with more modalities and scanning views attained superior performance to approximate that of experienced sonographers. The incorporation of multiple views and modalities of TTEs in the model enables accurate identification of children with CHD in a noninvasive manner, suggesting the potential to enhance CHD detection performance and simplify the screening process.

Assessment of Transcatheter or Surgical Closure of Atrial Septal Defect using Interpretable Deep Keypoint Stadiometry.

Automated echocardiogram interpretation with artificial intelligence (AI) has the potential to facilitate the serial diagnosis of heart defects by primary clinician. However, the fully automated and interpretable analysis pipeline for suggesting a treatment plan is largely underexplored. The present study targets to build an automatic and interpretable assistant for the transthoracic echocardiogram- (TTE-) based assessment of atrial septal defect (ASD) with deep learning (DL). We developed a novel deep keypoint stadiometry (DKS) model, which learns to precisely localize the keypoints, i.e., the endpoints of defects and followed by the absolute distance measurement with the scale. The closure plan and the size of the ASD occluder for transcatheter closure are derived based on the explicit clinical decision rules. A total of 3,474 2D and Doppler TTE from 579 patients were retrospectively collected from two clinical groups. The accuracy of closure classification using DKS (0.9425 ± 0.0052) outperforms the "black-box" model (0.7646 ± 0.0068; p < 0.0001) for within-center evaluation. The results in cross-center cases or using the quadratic weighted kappa as an evaluation metric are consistent. The fine-grained keypoint label provides more explicit supervision for network training. While DKS can be fully automated, clinicians can intervene and edit at different steps of the process as well. Our deep learning keypoint localization can provide an automatic and transparent way for assessing size-sensitive congenital heart defects, which has huge potential value for application in primary medical institutions in China. Also, more size-sensitive treatment planning tasks may be explored in the future.

Automated interpretation of congenital heart disease from multi-view echocardiograms.

Congenital heart disease (CHD) is the most common birth defect and the leading cause of neonate death in China. Clinical diagnosis can be based on the selected 2D key-frames from five views. Limited by the availability of multi-view data, most methods have to rely on the insufficient single view analysis. This study proposes to automatically analyze the multi-view echocardiograms with a practical end-to-end framework. We collect the five-view echocardiograms video records of 1308 subjects (including normal controls, ventricular septal defect (VSD) patients and atrial septal defect (ASD) patients) with both disease labels and standard-view key-frame labels. Depthwise separable convolution-based multi-channel networks are adopted to largely reduce the network parameters. We also approach the imbalanced class problem by augmenting the positive training samples. Our 2D key-frame model can diagnose CHD or negative samples with an accuracy of 95.4%, and in negative, VSD or ASD classification with an accuracy of 92.3%. To further alleviate the work of key-frame selection in real-world implementation, we propose an adaptive soft attention scheme to directly explore the raw video data. Four kinds of neural aggregation methods are systematically investigated to fuse the information of an arbitrary number of frames in a video. Moreover, with a view detection module, the system can work without the view records. Our video-based model can diagnose with an accuracy of 93.9% (binary classification), and 92.1% (3-class classification) in a collected 2D video testing set, which does not need key-frame selection and view annotation in testing. The detailed ablation study and the interpretability analysis are provided. The presented model has high diagnostic rates for VSD and ASD that can be potentially applied to the clinical practice in the future. The short-term automated machine learning process can partially replace and promote the long-term professional training of primary doctors, improving the primary diagnosis rate of CHD in China, and laying the foundation for early diagnosis and timely treatment of children with CHD.

Thrombotic storm in a 4-year-old boy with a thrombus in the right atrium.

Thrombotic storm (TS) is a rare disease, especially with thrombus in the heart of pediatric patient. We present a case of a 4-year-old boy, who was diagnosed with TS during his first hospitalization due to lower extremity deep venous thrombosis, pulmonary embolism, and thrombosis of the inferior vena cava, cerebral, left internal jugular, portal, renal, and iliac veins. He was eventually prescribed with rivaroxaban to control thrombosis after 30 days of successive use of low-molecular-weight heparin, unfractionated heparin, and warfarin, which were demonstrating little effect on preventing thrombosis, and the patient was intolerant to argatroban. While his lupus anticoagulant ratio was slightly above the normal range and no other potential causes such as congenital thrombophilia, severe infection, malignancy, and trauma were confirmed, we suspected antiphospholipid antibody syndrome and prescribed glucocorticoid and rituximab to control the disease. After 36 days of admission, ultrasonography showed recanalization of the former thrombus. One month after discharge, a tumor embolus resembling a mass emerged in his right atrium under effective anticoagulant therapy. During his second admission, he underwent surgical thrombectomy, and pathological examination confirmed the mass to be a platelet-rich thrombus rather than tumor embolus or infection. Considering the suspected antiphospholipid antibody syndrome as the cause of the TS, we prescribed aspirin combined with rivaroxaban to prevent thrombosis. In this case, surgery and pathology shed light on the type of thrombus that emerged from the inferior vena cava and traveled to the heart, which is the possible potential cause of TS. It also changed our therapeutic strategy to antiplatelet therapy combined with anticoagulant therapy to control the disease.

Congenital vascular rings: a rare cause of respiratory distress in infants and children.

BACKGROUND: Congenital vascular rings may often cause unexplained respiratory symptoms in infants and young children. Their diagnosis and treatment are often delayed. Few studies of vascular rings have been reported in China. The aim of this study was to describe the clinical presentation, diagnosis and surgical management of infants and children with congenital vascular rings. METHODS: Clinical histories, physical examinations, investigations, image studies and surgical interventions were retrospectively evaluated in 7 children (age range: 2 months-4 years, mean 7 months) with congenital vascular rings. Chest radiography was performed in all patients. Echocardiography and computed tomography (CT) with 3-dimensional (3D) reconstructions were performed in 6 patients. Esophagography, cardiac catheterization and angiography, and bronchoscopy were performed in 1, 1 and 4 children, respectively. RESULTS: Six of the 7 patients had respiratory symptoms, including recurrent cough, stridor and wheeze. Age at onset of symptoms ranged from 1 month to 11 months. Chest X-ray showed nothing important on the vascular rings, besides bronchitis and pneumonia. Contrast-enhanced CT diagnosed vascular rings in 6 patients. Four patients had double aortic arches, two had balanced arches and two were right arch dominant. One patient had a right aortic arch with left ligament and 1 patient had a pulmonary artery sling. Echocardiography failed to diagnose vascular rings in 2 patients. The esophagogram of 1 patient showed esophageal compression. Bronchoscopy of 4 patients showed compression of the distal trachea. Five of the 7 patients underwent surgical division of the vascular rings. Surgical observation confirmed the CT findings in each patient. CONCLUSIONS: Patients, especially infants or young children, with recurrent respiratory symptoms such as chronic cough, stridor and wheeze, should be examined for the possible presence of congenital vascular rings. Contrast-enhanced CT can clearly show the anatomy of vascular rings. As a noninvasive technique, echocardiography is helpful for diagnosis. Early surgical management in symptomatic patients is effective.

[Evaluation of coronary artery diameter in normal children by echocardiography and its clinical significance].

OBJECTIVE: To obtain normal range of coronary artery diameter with body surface area (BSA) dynamic changes in normal children at different age. METHOD: The left main coronary artery (LCA), left anterior descending artery (LAD), left circumflex artery (LCX) and the right coronary artery (RCA) diameter were measured in 400 normal subjects from Chinese population aged 0 d to 18 years [(6.43 ± 4.45) years], using HP Sonos 5500 color Doppler ultrasonic system, according to the standard method of measuring the coronary artery diameter. RESULT: (1) The diameters of LCA, LAD, LCX and RCA in different age groups (0 d-12 months, -3 years, -6 years, -9 years, -12 years, -18 years) had significant differences (F = 61.688, 51.343, 46.375, 50.192, P < 0.01,all groups mean differences had significant differences, there was significant difference between every two groups, P < 0.05), there were no significant differences between male and female subjects (P > 0.05). (2) The correlation analyses showed that the diameter of LCA, LAD, LCX and RCA had significant linear correlations with age, height, weight and BSA (r ranged from 0.71 to 0.85, P < 0.01 ). (3) The regression analyses were respectively performed on the diameters of LCA, LAD, LCX and RCA with BSA to establish seven regression models. The coefficients were compared for each model, the best model was chosen to create a Z score calculator, tracing out the Z value curve, through clinical practice,we chose Z score within ± 2 as the coronary artery diameter's normal range for Chinese children. CONCLUSION: Coronary artery diameter's Z score curve is effective and reliable, it provide objective basis for clinicians and sonographers to accurately and quickly diagnose the anomalies in diameter of coronary artery.