An electrocardiographic score to predict pulmonary hypertension in children with atrial septal defect.

BACKGROUND: In limited resource settings, identification of factors that predict the occurrence of pulmonary hypertension(PH) in children with atrial septal defect(ASD) is important to decide which patients should be prioritized for defect closure to prevent complication. Echocardiography and cardiac catheterization are not widely available in such settings. No scoring system has been proposed to predict PH among children with ASD. We aimed to develop a PH prediction score using electrocardiography parameters for children with ASD in Indonesia. METHODS: A cross-sectional study reviewing medical record including ECG record was conducted among all children with newly diagnosed isolated ASD admitted to Dr Sardjito Hospital in Yogyakarta, Indonesia during 2016-2018. Diagnosis of ASD and PH was confirmed through echocardiography and/or cardiac catheterization. Spiegelhalter Knill-Jones approach was used to develop PH prediction score. Accuracy of prediction score was performed using a receiver operating characteristic (ROC) curve. RESULTS: Of 144 children, 50(34.7%) had PH. Predictors of pulmonary hypertension were QRS axis ≥120°, P wave ≥ 3 mm at lead II, R without S at V1, Q wave at V1, right bundle branch block (RBBB), R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. ROC curve from prediction scores yielded an area under the curve (AUC) 0.908(95% CI 0.85-0.96). Using the cut-off value 3.5, this PH prediction score had sensitivity of 76%(61.8-86.9), specificity 96.8%(91.0-99.3), positive predictive value 92.7%(80.5-97.5), negative predictive value 88.4%(82.2-92.6), and positive likelihood ratio 23.8(7.7-73.3). CONCLUSIONS: A presence of PH in children with ASD can be predicted by the simple electrocardiographic score including QRS axis ≥120°, P wave ≥3 mm at lead II, R without S at V1, Q wave at V1, RBBB, R wave at V1, V2 or aVR > normal limit and S wave at V6 or lead I > normal limit. A total score ≥ 3.5 shows a moderate sensitivity and high specificity to predict PH among children with ASD.

Risk factors for healthcare-associated infection among children in a low-and middle-income country.

BACKGROUND: Healthcare-associated infections (HAI) are one of significant causes of morbidity and mortality. Evaluating risk factors associated with HAI are important to improve clinical outcomes. We aimed to evaluate the risk factors of HAI in children in a low-to middle-income country. METHODS: A prospective cohort study was conducted during 43 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to pediatric ICU and pediatric wards > 48 h were eligible. Those eligible patients were observed daily to identify the presence of HAI based on CDC criteria. The risk factors of HAI were identified. Multivariable logistic regression was used to identify independent risk factors. RESULTS: Total of 2612 patients were recruited. Of 467 were diagnosed as HAI. The cumulative incidence of HAI was 17.9%. In the multivariable analysis; length of stay > 7 days, severe sepsis, use of urine catheter, central venous catheter (CVC), non-standardized antibiotics, and aged < 1 year were independently associated with increased risk of HAI with adjusted OR (95%CI): 5.6 (4.3-7.3), 1.9 (1.3-2.9), 1.9 (1.3-2.6), 1.8 (1.1-2.9), 1.6 (1.2-2.0), and 1.4 (1.1-1.8), respectively. CONCLUSIONS: This study found that length of stay > 7 days, use of urine catheter and CVC, non-standardized antibiotic use, aged < 1 year, and had a diagnosis of severe sepsis increased risk of HAI.

The association between dietary intake and cardiometabolic risk factors among obese adolescents in Indonesia.

BACKGROUND AND OBJECTIVE: Poor diets, characterized by excess fat, sugar and sodium intakes, are considered to be one of the most important modifiable risk factors for cardiovascular disease. Diet patterns and intakes during adolescence may persist into adulthood and impact on risk for chronic disease later in life. We aimed to evaluate the dietary intake of obese adolescents and its relationship to cardiometabolic health including lipid status and glycemic control. METHODS AND STUDY DESIGN: This was a cross-sectional study of obese children aged 15 to < 18 years in Yogyakarta, Indonesia. All children had a medical history performed including a physical examination and fasting blood sample. Dietary intake was assessed using a semi-quantitative recall food frequency questionnaire. Multivariable linear regression model was performed to determine the relationship between dietary intakes and cardiovascular disease risks and to adjust for potential confounders. RESULTS: Of 179 adolescents, 101 (57.4%) were male and median age was 16.4 (15.0-17.9) years. The majority of adolescents (98%) had inadequate intake of fibre and exceeded intakes of total fat (65%) and total sugar (36%). There was statistically significant correlation found in the multivariable linear regression analysis between fibre intake and HDL cholesterol after adjusting for potential confounders (ß = 0.165; p = 0.033). CONCLUSIONS: This study demonstrates that there is a high proportion of obese Indonesian adolescents with poor dietary intakes. There was relationship observed between intake of nutrients of concern (fibre) and cardiometabolic risk factor among this sample of obese adolescents. Future research should examine overall dietary patterns in more detail among this population to elucidate the role of poor diet intakes in development of cardiovascular disease risk factors in young people transitioning into adulthood.

Feasibility of screening for critical congenital heart disease using pulse oximetry in Indonesia.

BACKGROUND: Screening of critical congenital heart disease (CCHD) using pulse oximetry is a routine procedure in many countries, but not in Indonesia. This study aimed to evaluate the feasibility of implementing CCHD screening with pulse oximetry for newborns in Yogyakarta, Indonesia. METHODS: A cross-sectional study was conducted at four hospitals in Yogyakarta, Indonesia. Newborns aged 24-48 hours who met the inclusion criteria were screened on the right hand and left or right foot using a pulse oximeter. Positive results were indicated by: either (1) SpO2 level < 90% in one extremity, (2) SpO2 level of 90-94% in both right hand and either foot on three measurements conducted 1 hour apart, or (3) a saturation difference > 3% between the upper and lower extremity on three measurements conducted 1 hour apart. Positive findings were confirmed by echocardiography. RESULTS: Of 1452 newborns eligible for screening, 10 had positive results and were referred for echocardiographic evaluation. Of those, 8 (6 per 1000 live birth, 8/1452) had CCHD. Barriers found during screening processes were associated with hospital procedures, equipment, healthcare personnel, and condition of the newborn. CONCLUSION: Pulse oximetry screening might be feasible to be implemented within the routine newborn care setting for CCHD in Indonesia. In order to successfully implement pulse oximetry screening to identify CCHD in Indonesia, the barriers will need to be addressed.

Delayed diagnosis in children with congenital heart disease: a mixed-method study.

BACKGROUND: Delayed diagnosis of congenital heart disease (CHD) causes significant morbidity and mortality. We aimed to determine the proportion of delayed diagnosis of CHD and factors related to the delayed diagnosis. METHODS: A prospective cohort study with mixed-methods was conducted in Dr. Sardjito Hospital, Yogyakarta, Indonesia. Patients aged < 18 years with newly diagnosed CHD and echocardiography confirmed CHD were included. Data were recorded from medical records and interviews from direct caregivers. Logistic regression was used to identify independent factors associated with the delay. RESULTS: A total of 838 patients were included with median age of 2.9 years (0-17.7 years), with female predominance (54.2%, n = 454). The proportions of delayed diagnosis were 60.8% (510), 54.9% (373) and 86.2% (137) in all children with CHD, acyanotic and cyanotic CHD, respectively. Delayed diagnosis by doctor was the most common cause, followed by delayed diagnosis related to midwifery care, financial, referral/follow-up, and social factors. In multivariate analysis, cyanotic CHD, residence outside the city, non-syndromic, low family income, normal labour and at term gestation at birth were independently associated with the delay. At diagnosis, heart failure and pulmonary hypertension occurred in 414 (49.4%) and 132 (15.8%) children with CHD, respectively. CONCLUSIONS: Six in ten children with CHD were diagnosed with significant delay. Delayed diagnosis by doctor was the most common cause. Children with cyanotic CHD, residence outside the city, non-syndromic, low family income, normal labour and at term gestation at birth were independently associated with the delay. Comorbid complications in delayed diagnosis of CHD were prevalent.

The screening of congenital heart disease by cardiac auscultation and 12-lead electrocardiogram among Indonesian elementary school students.

BACKGROUND: Screening for congenital heart disease (CHD) in school students is well-established in high-income countries; however, data from low-to-middle-income countries including Indonesia are limited. AIM: This study aimed to evaluate CHD screening methods by cardiac auscultation and 12-lead electrocardiogram to obtain the prevalence of CHD, confirmed by transthoracic echocardiography, among Indonesian school students. METHODS: We conducted a screening programme in elementary school students in the Province of Special Region of Yogyakarta, Indonesia. The CHD screening was integrated into the annual health screening. The trained general practitioners and nurses participated in the screening. The primary screening was by cardiac auscultation and 12-lead electrocardiogram. The secondary screening was by transthoracic echocardiography performed on school students with abnormal findings in the primary screening. RESULTS: A total of 6116 school students were screened within a 2-year period. As many as 329 (5.38%) school students were detected with abnormalities. Of those, 278 students (84.49%) had an abnormal electrocardiogram, 45 students (13.68%) had heart murmurs, and 6 students (1.82%) had both abnormalities. The primary screening programme was successfully implemented. The secondary screening was accomplished for 260 school students, and 18 students (6.9%) had heart abnormalities with 7 (2.7%) who were confirmed with septal defects and 11 (4.2%) had valve abnormalities. The overall prevalence was 0.29% (18 out of 6116). CONCLUSIONS: The primary screening by cardiac auscultation and 12-lead electrocardiogram was feasible and yielded 5.38% of elementary school students who were suspected with CHD. The secondary screening resulted in 6.9% confirmed cardiac abnormalities. The cardiac abnormality prevalence was 0.29%.

True Pathogen or Contamination: Validation of Blood Cultures for the Diagnosis of Nosocomial Infections in a Developing Country.

Background: Blood culture results are frequently used to guide antibiotic decision-making, but culture contaminants need to be distinguished from true pathogens. Aims: To assess the contamination rate of blood cultures and validate a method to distinguish between true bacteraemia and contamination. Methods: We analysed blood culture results from children who were admitted to the paediatric ICU and paediatric wards at the Sardjito Hospital, Yogyakarta, Indonesia between December 2010 and February 2013. For each positive culture result, the type of isolated organism, time to positivity, and the number of positive culture sites were considered to classify the isolate as representing a true bacteraemia or contaminant. Results: There were 1293 cultures obtained from blood and 308 (23.8%) were positive for bacterial growth. Fifty-three (4.1%) of the total cultures drawn fulfilled criteria for contaminants. The most common blood culture contaminants were coagulase-negative staphylococci. Conclusion: Using standardized criteria, it is possible to implement a working method to identify true nosocomial infection from blood culture contaminant, and thus limit the effect of contaminated blood culture on irrational antibiotic use.

Perioperative infections in congenital heart disease.

BACKGROUND: Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. METHODS: A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. RESULTS: Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. CONCLUSIONS: The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.

The global burden of paediatric heart disease.

An estimated 15 million children die or are crippled annually by treatable or preventable heart disease in low- and middle-income countries. Global efforts to reduce under-5 mortality have focused on reducing death from communicable diseases in low- and middle-income countries with little to no attention focusing on paediatric CHD and acquired heart disease. Lack of awareness of CHD and acquired heart disease, access to care, poor healthcare infrastructure, competing health priorities, and a critical shortage of specialists are important reasons why paediatric heart disease has not been addressed in low resourced settings. Non-governmental organisations have taken the lead to address these challenges. This review describes the global burden of paediatric heart disease and strategies to improve the quality of care for paediatric heart disease. These strategies would improve outcomes for children with heart disease.

ANTIBIOTIC RESISTANCE AND MORTALITY IN CHILDREN WITH NOSOCOMIAL BLOODSTREAM INFECTION IN A TEACHING HOSPITAL IN INDONESIA.

Nosocomial infection is a major problem in hospitals worldwide. Understanding patterns of bacterial etiology and antibiotic susceptibility are important factors to combating nosocomial infection. Among children with nosocomial bloodstream infection (BSI), we identified pathogens and determined antibiotics resistance patterns and mortality rates for antibiotic-susceptible and multidrugresistant (MDR) infection in patients with nosocomial BSI in pediatric wards and PICU at Dr Sardjito Hospital, Indonesia during December 2010 to February 2013. Of 174 isolates from 170 patients, 168 pathogens were bacteria, of which 148 were gram-negative. Pseudomonas aeruginosa, Klebsiella spp, Enterobacteriaceae, Acinetobacter baumanii, and Escherichia coli was found in 55%, 6%, 4%, 1%, and <1%, respectively of the isolates. Imipenem, amikacin, ciprofloxacin, and ceftazadime had the highest sensitivity to nosocomial pathogens at 86%, 84%, 84%, and 75%, respectively. Eleven patients had MDR-infections, 7 of whom died. Among 153 patients infected with bacteria resistant to <3 classes of antibiotics (non-MDR), mortality was 40%, and among 4 patients with fully drug-susceptible sepsis only one died. Thus, substantial mortality was observed in children with nosocomial-BSI, particularly with MDR pathogens. Given the further high risk of resistance with wider use of carbapenems, third generation cephalosporins and flouroquinolones, prevention should be given highest priority in combating hospital-acquired infection.

Outcome and factors associated with undernutrition among children with congenital heart disease.

BACKGROUND: Congenital heart disease (CHD) is associated with high morbidity and mortality, especially among those with undernutrition. Evaluating risk factors associated with undernutrition is important to improve clinical outcomes. We aimed to evaluate the outcome and factors associated with undernutrition among children with CHD. MATERIAL AND METHODS: A prospective cohort study was conducted among children with CHD at Dr. Sardjito Hospital, Yogyakarta, Indonesia during February 2016 to June 2018. Clinical and demographic data were collected at the time of diagnosis. Multivariate logistic regression analysis was used to identify independent factors associated with undernutrition using odds ratio (OR) and 95% confidence interval (CI). Significance was set as p<0.05. RESULTS: We recruited 1,149 children with CHD, of those, 563 (49%) were underweight, 549 (47.8%) were stunting, and 361 (31.4%) were wasting. In the multivariate analysis, cyanotic CHD, delayed diagnosis, congestive heart failure, pulmonary hypertension, syndrome, young maternal age, history of low birth weight, and being first child were independently associated with undernutrition. Underweight and stunting were significantly associated with increased mortality with OR of 3.54 (95% CI: 1.62-7.74), p<0.001 and OR 3.31 (95% CI: 1.65-6.64), p<0.001, respectively. CONCLUSIONS: About half of the children with CHD were categorized with undernutrition. An increased risk of undernutrition was associated with cyanotic CHD, delayed diagnosis, congestive heart failure, pulmonary hypertension, syndrome, low birth weight, and being first child. Underweight and stunting were significantly associated with increased risk of death.

Timeliness of routine childhood vaccinations in Indonesian infants in the first year of life.

BACKGROUND: Vaccines have proven to be one of the most effective strategies to control infectious diseases and contributed to childhood survival. While high vaccine coverages provide individual's and herd immunity, age-appropriate vaccination or vaccine timeliness is important for maximum vaccine's protection, but often not evaluated. We aimed to describe the timeliness of childhood vaccination for Indonesian infants and identify risk factors associated with delayed vaccination. METHODS: This study was a sub-study of the Indonesian Pneumonia and Vitamin D status (IPAD) study, a community-based cohort study to investigate pneumonia incidence in two districts in Yogyakarta province, Indonesia. Socio-demographic data were obtained from structured interviews and vaccine status was obtained from maternal and child health records. Timely vaccination was defined if the vaccine was received between four days or less before and within 28 days after the recommended age of vaccination. RESULTS: 359 (85%) out of 422 IPAD participants and their immunisation records were included. Between December 2015 and December 2017, vaccination coverage was high and ranged from 96.1% (Measles) to 100% (DTP-HepB-Hib 1). However, two thirds (67%, 242/359) of all participants had received either early or late vaccines, with dose 2 IPV (40%, 143/356), dose 3 IPV (56%, 196/349) and dose 3 DTP-HepB-Hib (29%, 103/354) most delayed, and only 1% received early doses. The main risk factors for untimely vaccination were if the infant was born in a private practice versus in a public health facility (AOR 1.90; 95% CI: 1.18-3.07) and rural residence (AOR 1.84; 95% CI: 1.15-2.94). CONCLUSIONS: Despite high vaccine coverage for Indonesian infants (>95%), two thirds (67%) of infants had untimely vaccinations, with dose 3 IPV (56%) the most delayed. Future strategies should focus on coordination between government, health care providers, and carers to ensure timely access and vaccination of infants to ensure adherence to vaccination schedules.

The feasibility of SARS-CoV-2 surveillance using wastewater and environmental sampling in Indonesia.

BACKGROUND: Wastewater-based epidemiology (WBE) surveillance as an early warning system (EWS) for monitoring community transmission of SARS-CoV-2 in low- and middle-income country (LMIC) settings, where diagnostic testing capacity is limited, needs further exploration. We explored the feasibility to conduct a WBE surveillance in Indonesia, one of the global epicenters of the COVID-19 pandemic in the middle of 2021, with the fourth largest population in the world where sewer and non-sewered sewage systems are implemented. The feasibility and resource capacity to collect samples on a weekly or fortnightly basis with grab and/or passive sampling methods, as well as to conduct qualitative and quantitative identification of SARS-CoV-2 ribonucleic acid (RNA) using real-time RT-PCR (RT-qPCR) testing of environmental samples were explored. MATERIALS AND METHODS: We initiated a routine surveillance of wastewater and environmental sampling at three predetermined districts in Special Region of Yogyakarta Province. Water samples were collected from central and community wastewater treatment plants (WWTPs), including manholes flowing to the central WWTP, and additional soil samples were collected for the near source tracking (NST) locations (i.e., public spaces where people congregate). RESULTS: We began collecting samples in the Delta wave of the COVID-19 pandemic in Indonesia in July 2021. From a 10-week period, 54% (296/544) of wastewater and environmental samples were positive for SARS-CoV-2 RNA. The sample positivity rate decreased in proportion with the reported incidence of COVID-19 clinical cases in the community. The highest positivity rate of 77% in week 1, was obtained for samples collected in July 2021 and decreased to 25% in week 10 by the end of September 2021. CONCLUSION: A WBE surveillance system for SARS-CoV-2 in Indonesia is feasible to monitor the community burden of infections. Future studies testing the potential of WBE and EWS for signaling early outbreaks of SARS-CoV-2 transmissions in this setting are required.

Transcatheter Closure of Perimembranous Ventricular Septal Defect Using the Lifetech Konar-Multi Functional Occluder: Early to Midterm Results of the Indonesian Multicenter Study.

Background: The alternative device to close perimembranous ventricular septal defect (pmVSD) has been searched for better result, less complications and applicable for infants. However, the ideal device is still unavailable. We aimed to evaluate the effectiveness and outcome of transcatheter pmVSD closure using the KONAR-multi functional occluder (MFO). Methods: Clinical, procedural, follow-up data of pmVSD patients with symptom of heart failure or evidence of significant left to right shunt, growth failure, recurrent respiratory tract infection, and history of endocarditis who underwent transcatheter closure using the MFO were prospectively evaluated. Results: Between January 2016 and December 2017, there were complete records of 132 pmVSD children closed using MFO from eleven centers in Indonesia. The median of age was 4.5 (0.3-17.4) years; weight 14.8 (3.5-57) kg, defect size at the smallest part 3.4 (1.0-8.1) mm, flow ratio 1.6 (1.3-4.9), mean pulmonary artery pressure 18 (7-79) mmHg, fluoroscopy time 18 (3.8-91) and procedural time 75 (26-290) minutes. A retrograde approach was done in 41 (31%) patients. Procedures succeeded in first attempt in 126 (95.4%), failed in three and migration in three patients. Six of eight infants with congestive heart failure were closed successfully. Of 126 patients with successful VSD closure, 12 months follow-up were completed in all patients. The rate of complete occlusion at 1 month, 3 months, 6 months and 12 months after intervention were 95.2%, 97.6%, 99.2%, and 99.2%, respectively. New-onset aortic regurgitation and moderate tricuspid regurgitation developed only in five and three patients. Neither complete atrioventricular block, nor other complications occurred. Conclusion: Transcatheter closure of pmVSD using the MFO is safe, effective, and feasible in infants and children.

Potential Role of Vitamins and Zinc on Acute Respiratory Infections Including Covid-19.

Background. Vitamin C, E, D, A, zinc are considered to be essential in preventing and treating of acute respiratory infections (ARI) including COVID-19. Methods. We reviewed published studies evaluating the potential roles of these vitamin and zinc for ARIs and COVID-19 using Medline database, medRxiv, and bibliographic references. Results. Vitamins C, D, and E did not reduce incidence of common cold in general, but vitamin C reduced by half in population with physical and environment stresses. Vitamins C and E shortened duration and reduced severity of common cold. A large-dose vitamin A had no effect on recovery from pneumonia. Zinc improved clinical deterioration and pneumonia duration in under five. The effect on preventing COVID-19 morbidity and related-death was lacking. Conclusions. Although the effects of vitamins and zinc on ARIs including COVID-19 were inconclusive, taking these for a short period during pandemic may be beneficial when there is risks of deficiency.

Sex differences in the association of vitamin D and metabolic risk factors with carotid intima-media thickness in obese adolescents.

BACKGROUND: It has been shown that vitamin D is associated with obesity and the development of atherosclerosis. Less is known about this association among adolescents with obesity. OBJECTIVES: To determine the association of vitamin D level and metabolic risk factors with carotid intima-media thickness (CIMT) among obese adolescents. METHODS: We conducted a cross-sectional study among obese children aged 15 to 17 years in Yogyakarta, Indonesia. The association of vitamin D and other metabolic risk factors (triglyceride, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), and insulin resistance using homeostasis model assessment of insulin resistance (HOMA-IR)) with CIMT was explored by multivariable linear regression models. RESULTS: Out of 156 obese adolescents, 55.8% were boys. Compared to girls, boys had higher BMI z-score, waist circumference, and HDL-cholesterol. After adjustment for age, sex and second-hand smoke exposure, high HOMA-IR, total cholesterol, LDL-cholesterol and triglyceride levels were associated with higher odds of elevated CIMT. In analyses stratified by sex, a similar trend was observed in boys, while none of the risk factors were associated with CIMT in girls. We observed no association between vitamin D and CIMT. CONCLUSIONS: Hyperinsulinemia, higher total cholesterol and LDL cholesterol were associated with greater odds of elevated CIMT among obese adolescent boys.

Outcome in children with newly diagnosed rheumatic heart disease in Indonesia.

BACKGROUND: Rheumatic heart disease (RHD) is associated with high morbidity and mortality, especially in those with severe RHD or progression of valvular disease (VD). Evaluation of the factors that predict valvular progression is important in order to improve clinical outcome. AIM: To evaluate outcome and clinical predictors of valvular progression in children with newly diagnosed RHD. METHODS: A retrospective cohort study was conducted in children with newly diagnosed RHD at Dr Sardjito Hospital, Yogyakarta, Indonesia during 2013-2020. Clinical and echocardiography data at the time of diagnosis were collected and patients were followed up for 1 year. Echocardiography evaluations were undertaken to determine the progression of VD. Independent predictors of valvular progression were identified by Cox regression analysis. RESULTS: A total of 77 patients were recruited, 36 (46.7%) of whom were male, and the median age (range) was 12.3 years (5.9-17.8). Thirty-three (42.8%) had progression of VD in the year after diagnosis. By multivariable analysis, an age at diagnosis of >10 years and high C-reactive protein (CRP) were independently associated with an increased risk of valvular progression with an adjusted hazard ratio (95% CI) of 3.23 (1.09-9.60) and 3.69 (1.45-9.67), respectively. CONCLUSION: After only 1 year of follow-up, approximately four in 10 children with newly diagnosed RHD developed progression of VD. An increased risk of valvular progression was associated with being over 10 years of age and a high level of CRP.

Survival of Left-to-Right Shunt Repair in Children with Pulmonary Arterial Hypertension at a Tertiary Hospital in a Low-to-Middle-Income Country.

Background: In low-to-middle-income countries, repair of the left-to-right shunts congenital heart disease (CHD) are often done with existing pulmonary arterial hypertension (PAH). Long-term outcomes data of this condition in either low-to-middle or high-income countries are limited. We conducted a study to evaluate the outcomes of children with PAH related to left-to-right shunt CHD who underwent surgical or transcatheter repair. Methods: All cases of PAH related to left-to-right shunt CHD repairs from 2015-2018 were retrospectively reviewed with additional new patients who underwent repair within our study period (2019-2020). Cases with complex congenital heart disease and incomplete hemodynamic echocardiography or catheterization measurements were excluded. Kaplan-Meier curves, log-rank test, Cox regression with Firth's correction and restricted mean survival time were used for survival analysis. Results: Of the 118 patients, 103 patients were enrolled and 15 patients were excluded due to complex congenital heart disease and missing hemodynamic measurements prior to repair. Overall, median age at intervention was 44 months, mPAP mean was 43.17 ± 16.05 mmHg and Pulmonary Vascular Resistance index (PVRi) mean was 2.84 ± 2.09 (WU.m2). Nine patients died after repair. The survival rate for patients with PAH-CHD at 1 day, 30 days and 1400 days (4 years) was 96.1%, 92.1%, and 91.0% respectively. Patients with persisting PAH after correction had -476.1 days (95% confidence interval [CI]: -714.4, -237,8) shorter survival over 4 years of follow up compared to patients with reversed PAH. PVRi was found to be the influencing covariate of the difference of restricted mean survival time between these groups. Conclusion: In low-to-middle income settings, with accurate PAH reversibility assessment prior to intervention, repair of left-to-right shunt CHD with existing PAH in children has a favourable outcome. Inferior survival is found in patients with persistence of PAH. PVRi at baseline predicts between-group survival difference.

Risk of metabolic syndrome and early vascular markers for atherosclerosis in obese Indonesian adolescents.

Background: The prevalence of childhood obesity has increased in low- and middle-income countries, including Indonesia. It is important to identify risk factors for cardiovascular disease in obese adolescents in this region.Aim: To assess the risk of metabolic syndrome and early vascular markers for atherosclerosis in obese Indonesian adolescentsMethods: A cross-sectional study was undertaken in obese high school students aged 15-<18 years in Yogyakarta, Indonesia. All eligible adolescents were interviewed about their medical history, were physically examined and had a fasting blood sample taken. Arterial stiffness was measured during systole and diastole blood pressure, endothelial dysfunction was estimated using flow-mediated dilation (FMD) and arterial wall thickness using carotid artery intima-media thickness (CIMT).Results: A total of 4268 students were screened, 298 (7%) of whom were classified as obese. Of those, 229 had blood samples taken, 173 had FMD performed and 156 had CIMT examination. Adolescents with a higher body mass index or BMI Z-score (>3.0) had a significantly poorer lipid profile, insulin level and homeostasis model assessment of insulin resistance (HOMA-IR) than those with a lower BMI Z-score. There were no significant differences for early vasculature markers for atherosclerosis between these two groups.Conclusion: The prevalence of risks of cardiovascular disease in obese adolescents was significant. The higher the BMI Z-score, the higher the risks of cardiovascular disease. Interventions to reduce obesity and its cardiovascular disease morbidities are urgently needed in low- and middle-income countries.Abbreviations: BMI; body mass index; CIMT, carotid artery intima-media thickness; CDC, Centers for Disease Control and Prevention; FMD flow-mediated dilation; HDL high-density lipoprotein cholesterol; HbA1c haemoglobin A1c; HOMA-IR, homeostasis model assessment of insulin resistance; IOTF, International Obesity Task Force; LDL, low-density lipoprotein cholesterol; WHO, World Health Organization.

Multifaceted interventions for healthcare-associated infections and rational use of antibiotics in a low-to-middle-income country: Can they be sustained?

BACKGROUND: Transmission of infection between patients by health workers, and the irrational use of antibiotics are preventable causes for healthcare-associated infections (HAI) and multi-resistant organisms. A previous study implementing a hand hygiene campaign and antibiotic stewardship program significantly reduced these infections. Sustaining such interventions can be challenging. AIMS: To evaluate whether there was a sustained effect of a multifaceted infection control and antibiotic stewardship program on HAI and antibiotic use 5 years after it began. METHODS: A prospective evaluation study was conducted over 26 months (from February 2016 to April 2018) in a teaching hospital in Indonesia, 5 years after the implementation of an antibiotic stewardship and infection control program, which was successful when initially evaluated. All children admitted to the pediatric ICU and pediatric wards were observed daily. Assessment of HAI was made based on the criteria from the Centers for Disease Control and Prevention. Assessment of rational antibiotic use was based on the WHO Pocket Book of Hospital Care for Children. Multivariable logistic regression analysis was used to quantify the relationship between the HAI and the multifaceted intervention. RESULTS: We observed an increase in HAIs, from 8.6% (123/1419 patients) in the initial post-intervention period in 2011-2013 to 16.9% (314/1855) in the evaluation study (relative risk (RR) (95% CI) 1.95 (1.60 to 2.37)). After adjusting for potential confounders, we found that an increase in HAI in the evaluation period with adjusted OR 1.94 (95% CI 1.53 to 2.45). Inappropriate antibiotic use also increased, from 20.6% (182 of 882 patients who were prescribed antibiotics) to 48.6% (545/1855) (RR 2.35 (2.04 to 2.71)). Hand hygiene compliance also declined from 62.9% (1125/1789) observed moments requiring hand hygiene to 51% (1526/2993) (RR 3.33 (2.99 to 3.70)). CONCLUSIONS: Healthcare-associated infections and irrational use of antibiotics remain significant even after the implementation of a multifaceted infection control intervention and antibiotic stewardship program. There is a need for continuous input, ongoing surveillance and long-term monitoring of these interventions to sustain compliance and effectiveness and address problems as they emerge.