Disparities Regarding Inadequate Automated External Defibrillator Training and Potential Barriers to Successful Cardiac Resuscitation in Public School Systems.

Installation of automated external defibrillators (AEDs) in public schools has been shown to improve outcomes for children with sudden cardiac arrest (SCA). However, the adequacy of faculty AED training and potential barriers to successful cardiac resuscitation remain unknown. A questionnaire was mailed to all public schools in the state of Illinois (n = 3796). The survey focused on the demographic variables of each school as well as the confidence of the responder regarding effectiveness of AED training. 2,192 surveys were included in this study (58% response rate). Independent variables for perceived inadequate AED training were schools that were predominantly black (odds ratio [OR] 3.93; 3.01 to 5.13) or Hispanic (OR 2.75; 2.11 to 3.58), elementary schools (OR 2.05; 1.69 to 2.50), schools with <250 students (OR 1.69; 1.19 to 2.40) and <25 faculty (OR 1.54; 1.10 to 2.15). Eighty-eight percent of responders cited at least one barrier to successful AED utilization. Location in a town setting (OR 9.34; 4.73 to 18.44) or rural setting (OR 3.18; 2.47 to 4.10) as well as upper socioeconomic status (OR 3.85; 2.04 to 7.29) were found to be predictors of schools with no barriers to AED utilization.

Quality outcomes of ACHD patients undergoing cardiovascular procedures and hospital admissions in a free-standing children's hospital.

OBJECTIVES: Describe quality outcomes of adults with congenital heart disease (ACHD) undergoing cardiovascular procedures and admissions in a free-standing children's hospital with a multi-disciplinary ACHD program and compared with pediatric outcomes. BACKGROUND: A challenge for the U.S. healthcare system is where to treat the >1 million ACHD patients (pts): adult hospitals without CHD care, or pediatric hospitals without adult services. METHODS: We reviewed all CHD pts ≥ 18 yrs of age from 2002-2007. Procedural and hospital related morbidity and mortality were recorded. ANOVA and t-test compared adult with pediatric pts. RESULTS: Overall, 782 pts, mean age of 29.8 ± 9.9 yrs, encountered 1490 procedures/admissions. For 178 cardiac surgeries (72% reoperations), mortality was 1.8% and complication rate was 7.3%. There was 0% mortality for 412 cardiac catheterizations, 311 electrophysiological procedures, 401 transesophageal echocardiograms (TEE), 244 exercise tests (ETT) and 54 medical admissions. Major adverse event rate was 0.6% for cardiac catheterization and electrophysiological procedures. No adverse events occurred during TEE and ETT. Only 4 pts required transfer to an adult institution (0.25%). There was no significant difference in mortality or adverse events between pediatric and adult CHD pts, p>0.05. CONCLUSIONS: The optimal setting to provide ACHD care remains a complex issue. Our study is the first to demonstrate 1) a low incidence of morbidity and mortality for ACHD pts undergoing cardiovascular procedures or admissions at a free-standing children's hospital, 2) outcomes comparable to pediatric CHD pts. Future models incorporating ACHD programs within pediatric heart centers should be considered to care for this complex population.

Rate of inducible ventricular arrhythmia in adults with congenital heart disease.

Patients with adult congenital heart disease are at increased risk of ventricular arrhythmia (VA) and sudden cardiac death, although no clear predictors have been found. Ventricular programmed stimulation has been shown to predict clinical ventricular tachycardia and sudden death events, but the role of screening electrophysiology studies (S-EPSs) in this population remains poorly defined. Therefore, we sought to determine the prevalence of inducible VA and to evaluate the clinical predictors in a heterogeneous group of patients with adult congenital heart disease (> or =18 years old) undergoing S-EPSs at preoperative or interventional cardiac catheterization. Studies for the primary evaluation of clinical VA were excluded. The demographic, clinical, and diagnostic findings were compared between the patients with positive and negative findings. From 2005 to 2009, 80 patients (mean age 30 +/- 9 years) underwent S-EPSs, and 23 had inducible VA. The diagnoses for those with studies positive for VA included tetralogy of Fallot (n = 12), d-transposition of the great arteries (n = 6), pulmonary stenosis (n = 2), double outlet right ventricle (n = 1), double inlet left ventricle (n = 1), and Ebstein's anomaly (n = 1). Men were significantly more likely to have a S-EPS positive for VA (p = 0.015). Increasing QRS duration, decreasing peak oxygen uptake (percentage of predicted), and ventricular fibrosis with cardiovascular magnetic resonance imaging were significantly associated with studies positive for VA (p <0.05). Combined fibrosis and a peak oxygen uptake <80% of predicted had 100% sensitivity for positive VA findings. In conclusion, almost 30% of those with adult congenital heart disease undergoing S-EPSs had inducible VA. A prolonged QRS duration, diminished exercise capacity, and the presence of ventricular fibrosis were significantly associated with findings positive for VA and might improve patient selection for screening evaluations.

Tissue doppler changes in pediatric complete heart block patients who are chronically paced.

INTRODUCTION: Pediatric patients with complete heart block (CHB) often require pacemaker therapy. Adult studies have shown chronic right ventricular pacemaker therapy may be associated with decreased echocardiographic parameters and increased brain natriuretic peptide (BNP) values. The goal of this study was to determine if there are echocardiographic or BNP changes in a pediatric population that is chronically paced. METHODS: Patients were recruited if they had CHB and had a pacemaker. Patients were excluded if they had congenital structural heart disease. Standard two-dimensional echocardiograms, including tissue Doppler imaging (TDI), were performed. BNP values were obtained. Nonparametric Spearman's rank correlation was used for analysis. Rho < or = 0.05 was considered significant. RESULTS: Eighteen patients (16.4 +/- 7.3 years) with CHB were studied. Age at implant was 8.6 +/- 6.6 years and length of pacing was 7.8 +/- 6.6 years. Pacing mode was VDD, DDD, DDDR, or VVIR. All patients were ventricularly paced >95% of the time. Ejection fraction was 58.5 +/- 7.5%. All BNP values were <40 pg/mL. There was no correlation between ejection fraction or BNP level with the length of pacing years. Pacing years significantly correlated with mitral and tricuspid E/A ratios (rho =-0.56, -0.56, respectively). Pacing years also correlated with right ventricular and interventricular TDI a wave (rho = 0.61 and 0.68, respectively). Furthermore, pacing years correlated with right ventricular TDI e/a ratio (rho =-0.58). CONCLUSIONS: Ejection fraction and BNP levels were not sensitive parameters in evaluating pediatric patients who are chronically paced. Subtle diastolic changes, especially of the right ventricle, were detected by TDI.

CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases.

OBJECTIVE: CT cystography has replaced conventional cystography in the evaluation of patients with suspected bladder rupture in most trauma centers. We performed this retrospective review to determine the accuracy of CT cystography and the role of multiplanar reformation in the diagnosis of bladder injury. MATERIALS AND METHODS: The patient cohort was composed of trauma patients with clinically or CT-suspected bladder ruptures who were evaluated with CT cystography using two different MDCT scanners at our level 1 trauma center. The patients were identified through Folio, a radiology research tool software system. The CT cystography results were compared with the findings at surgery, clinical follow-up, or both. RESULTS: Between January 1, 2000, and December 31, 2004, 234 patients were examined in our level 1 trauma center with CT cystography. From the total of 234 examinations, 216 (92.3%) were interpreted as negative and 18 examinations (7.7%) were interpreted as positive. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Surgical bladder exploration and repair were performed in nine of the 18 cases. Seven (77.8%) of the nine cases had operative findings consistent with the CT cystogram findings. The overall sensitivity and specificity of CT cystography in diagnosing bladder rupture were each 100%. For extraperitoneal bladder rupture, the sensitivity and specificity were 92.8% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively. CONCLUSION: CT cystography is accurate for diagnosing bladder rupture. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture.

Ophthalmic complications of dengue.

We report 13 cases of ophthalmic complications resulting from dengue infection in Singapore. We performed a retrospective analysis of a series of 13 patients with dengue fever who had visual impairment. Investigations included Humphrey automated visual field analyzer, Amsler charting, fundus fluorescein angiography, and optical coherence tomography. Twenty-two eyes of 13 patients were affected. The mean age of patients was 31.7 years. Visual acuity varied from 20/25 to counting fingers only. Twelve patients (92.3%) noted central vision impairment. Onset of visual impairment coincided with the nadir of serum thrombocytopenia. Ophthalmologic findings include macular edema and blot hemorrhages (10), cotton wool spots (1), retinal vasculitis (4), exudative retinal detachment (2), and anterior uveitis (1). All patients recovered visual acuity to 20/30 or better with residual central scotoma by 12 weeks. These new complications suggest a widening spectrum of ophthalmic complications in dengue infection.

Chest radiograph scores as potential prognostic indicators in severe acute respiratory syndrome (SARS).

OBJECTIVE: We analyzed serial chest radiographic scores for lung opacification in patients with severe acute respiratory syndrome (SARS) for temporal changes and differences between fatal and discharged cases. We sought to establish the earliest radiographic scores sensitive as potential prognostic indicators of fatal outcomes. MATERIALS AND METHODS: Chest radiographs that had been obtained from presentation until the death or discharge of 313 patients with SARS were scored on the basis of the percentage area and location of lung opacification. Profile analysis and univariable logistic regression were performed on these radiographic scores. RESULTS: Despite the increased mortality risks of advanced age and male sex, no significant difference was seen in the percentage area of opacification (AO%) between the sexes in either the group of patients with fatal outcomes or the group of patients who were discharged. No difference existed between age groups (< 65 years vs >/= 65 years), except for the radiograph showing the peak lung opacification in the deceased group in which the lungs of older patients had less opacification than those of younger patients. The radiographic scores obtained by day 7 were the earliest ones with good performance in prognostic prediction. The model showed good discriminatory performance, indicated by high C-indexes for receiver operator characteristic curves (0.86 for AO% and 0.90 for the number of opacified zones). The predicted proportion of patients with fatal outcomes showed high agreement with percentage of patients who died (goodness-of-fit statistic p = 0.18 for AO%, 0.73 for the number of opacified zones). By day 7, crude odds ratio of death was 1.73 per 5% of AO% (p < 0.0001) or 2.93 per lung zone opacified (p < 0.0001). CONCLUSION: Chest radiographic scores (percentage of lung or the number of zones opacified) by day 7 could be used as fatal prognostic indicators.

Persistent electrical and morphological atrial abnormalities after early closure of atrial septal defect.

Atrial arrhythmias are associated with enlarged atrial chambers and an increased duration of the P wave. Repair of atrial defects within the oval fossa is expected to normalize atrial size. Few studies, however, have evaluated electrical and morphological atrial features after repair. Our study was performed to determine if atrial abnormalities exist after surgical closure of such atrial septal defects, and whether early closure improves outcome. We recruited patients who had undergone surgical closure of a defect within the oval fossa, so-called "secundum" atrial septal defects. Electrocardiograms, signal averaged electrocardiograms, and echocardiograms were performed. Two-tailed test and Pearson correlation was utilized for statistical analysis. The population consisted of 20 patients and 27 controls, with the mean age of the patient being 11.25 +/- 5.10 years, their age at surgery 6.55 +/- 5.10 years, and the time since surgery 4.70 +/- 2.61 years. The size of the right (23.88 +/- 6.35 ml/m2 versus 18.84 +/- 4.43 ml/m2) and left (21.91 +/- 12.47 ml/m2 versus 17.72 +/- 4.83 ml/m2) atrium were significantly larger in the patients. The duration of the P wave (108 +/- 16 ms versus 96 +/- 8 ms) and the duration of the PR interval (155 +/- 18 ms versus 138 +/- 23 ms) were longer. No correlation existed between age or interval since surgery with atrial sizes or measurements of the signal averaged electrocardiogram. We conclude that, despite surgical repair, abnormalities exist in patients with an atrial septal defect. Early surgery does not appear to prevent the atrial abnormalities.

Cystic pulmonary metastases from epithelioid cell sarcoma.

A patient with cystic pulmonary metastases, from epithelioid sarcoma of the thigh, resulting in bilateral pneumothoraces is presented. The pulmonary metastases superficially resembled pneumomatoceles and were not visible on radiography. Computed tomography examinations over a 10-month period showed no change in the size or number of the cystic metastases, though air fluid levels and pericystic nodular consolidation (probably due to pulmonary hemorrhage) did occur and regress. This case report serves to emphasize that bullous type lesions on thoracic computed tomography in patients with a known sarcoma should be interpreted with particular caution.