Behavioural interventions to increase adherence to palivizumab prophylaxis in children with CHD.

OBJECTIVES: Adherence to palivizumab prophylaxis programmes is crucial to protect infants with CHD against respiratory syncytial virus infections. We analysed the effectiveness of two nudge interventions in increasing adherence. METHODS: Our study included 229 infants, and their caregivers, from five centers in Turkey in the 2020-2021 respiratory syncytial virus season. We randomly allocated caregivers to a control and two intervention groups. Caregivers in all groups were informed about the prophylaxis programme and provided a schedule. Additionally, caregivers in Intervention 1 were called two days before appointments (default bias) and were asked to plan the appointment day (implementation intention), whereas caregivers in Intervention 2 received biweekly text messages informing them about the programme's benefits (availability bias) and current adherence rate (social norm). RESULTS: Caregivers in Intervention 1 had a significantly higher adherence rate than Control (97.3% versus 90.9%) (p = 0.014). Both interventions had a significant effect on participants in their first prophylaxis season (p = 0.031, p = 0.037). Families where the father was employed had a 14.2% higher adherence rate (p = 0.001). Every additional child was associated with a 2.2% decrease in adherence rate (p = 0.02). In control, ICU admission history was associated with an 18.8% lower adherence rate (p = 0.0001), but this association disappeared in intervention groups. CONCLUSION: This is the first prospective interventional study which, in the context of palivizumab prophylaxis, analyses the effectiveness of nudge interventions based on established cognitive biases by comparing randomly generated intervention and control groups. We found that default bias and implementation intention have significant effects on adherence.Clinical trial, in the name and number "Adherence of palivizumab prophylaxis, NCT05778240" registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT05778240.

Ivabradine in a 15-day-old male neonate with refractory focal atrial tachycardia.

Ivabradine is used to reduce heart rate in children with chronic heart failure and dilated cardiomyopathy, it has recently been used off-label to treat tachyarrhythmias such as ectopic atrial tachycardia and junctional ectopic tachycardia (JET) in children. We report a successful ivabradine experience in a male neonate with refractory focal atrial tachycardia (FAT).

Late-term cardiac magnetic resonance imaging in multisystem inflammatory syndrome in children.

BACKGROUND: Cardiac involvement in multisystem inflammatory syndrome in children may have a spectrum ranging from mild disease to severe heart failure due to fulminant myocarditis. Cardiac involvement usually resolves after clinical recovery. However, the adverse effects of myocarditis on cardiac function after recovery are not fully known. This study aims to investigate cardiac involvement by performing cardiac magnetic resonance imaging (MRI) after the acute and recovery periods. METHODS: 21 patients with clinical and laboratory signs of myocarditis, including left ventricular systolic dysfunction, mitral regurgitation, elevated troponin T, elevated N-terminal pro-B-type natriuretic peptide and electrocardiographic changes, who had given consent for cardiac MRI, underwent cardiac MRI after completion of the acute and recovery phases. RESULTS: When compared to 16 patients with normal cardiac MRI, five patients with cardiac fibrosis on MRI were older, had greater body mass indexes, lower leucocyte counts, lower neutrophil counts, higher blood urea nitrogen levels and higher creatinine levels. Cardiac fibrosis on MRI was located in the posterior right ventricle insertion point and in mid ventricular septum. CONCLUSIONS: Adolescence and obesity appear as risk factors for the development of fibrosis as a late-term sequela of myocarditis. Furthermore, future studies reporting the follow-up data of patients with fibrosis are necessary to predict and manage adverse outcomes.

Evaluation of tumour necrosis factor alpha-stimulated gene-6 and fibroblast growth factor-2 levels in patients diagnosed with multi-system inflammatory syndrome in children.

Investigations are still ongoing about the pathophysiology of multi-system inflammatory syndrome in children, which can progress with serious morbidity and mortality after COVID-19 infection. In this study, we aimed to investigate whether fibroblast growth factor-2 and tumour necrosis factor alpha-stimulated gene-6 levels play a role in the diagnosis of the disease and on cardiac involvement. Twenty-three patients (11 girls, 12 boys) and 26 healthy controls (10 girls, 16 boys) were included in the study. The mean age of the patient and control group was 8.45 ± 2.43 and 10.73 ± 4.27 years, respectively. There was no difference between the fibroblast growth factor-2 and tumour necrosis factor alpha-stimulated gene-6 levels of the patient and control groups. When the patients with myocardial involvement in the patient group were compared with the patients without myocardial involvement in terms of fibroblast growth factor-2 and tumour necrosis factor alpha-stimulated gene-6 levels, no difference was found between these groups. The correlation of fibroblast growth factor-2 and tumour necrosis factor alpha-stimulated gene-6 levels with other laboratory parameters was investigated in the patient group. Fibroblast growth factor-2 was moderately inversely correlated with white blood cell count (r = -0.541, p = 0.008), absolute neutrophil count (r = -0.502, p = 0.015) and C-reactive protein (r = -0.528, p = 0.010). Fibroblast growth factor-2 was strongly inversely correlated with erythrocyte sedimentation rate (r = -0.694, p =<0.001). Our data show that fibroblast growth factor-2 and tumour necrosis factor alpha stimulated gene-6 do not provide sufficient information about diagnosis and cardiac involvement in multi-system inflammatory syndrome in children.

Does the use of proton pump inhibitors in children affect ventricular repolarisation parameters?

Proton pump inhibitors are widely used agents in the treatment of dyspepsia, and their effects on ventricular repolarisation through ion channels are well-known. Our aim is to evaluate the change in ventricular repolarisation parameters on electrocardiogram before and after proton pump inhibitor treatment. This study included 69 patients who had symptoms such as burning stomach pain, bloating, nausea, and heartburn for at least 3 months. Electrolyte levels of the patients were measured before and after treatment, and 12-lead electrocardiograms were taken at the initial and 1st month follow-up visit. Heart rate, QT interval, corrected QT (QTc), QT dispersion (QTd), QTc dispersion (QTcd), Tp-e measurements, and Tp-e/QT ratio were calculated and compared. Thirty-nine of the patients were girls, 30 were boys, and the mean age was 13.16 ± 3.02 years. Electrolyte levels of the patients before and after treatment were within the normal range. There was no statistically significant difference in the QTc, the Tp-e duration, or the Tp-e/QT ratio of the patients before and after treatment. We did not find a significant prolongation in the QTc duration or any other ventricular repolarisation parameters after proton pump inhibitor treatment in children with dyspepsia. We did not observe ventricular arrhythmia in our patients during follow-up. However, different results might be obtained with a larger sample and a longer follow-up period. These patients may have an increased risk of developing ventricular arrhythmias. Therefore, precaution should be taken when using drugs that prolong the QT period, and follow-up with serial electrocardiograms should be planned.

Does transcatheter ventricular septal defect closure affect heart rate variability in children?

BACKGROUND: Heart rate variability (HRV) is a sign of the cardiac autonomic nervous system. Its evaluation in pediatric ventricular septal defect (VSD) cases before and after transcatheter closure contributes to an understanding of cardiac autonomic control. METHODS: Nineteen children with VSDs treated with transcatheter closure and 18 healthy children were enrolled in this study. A 24-h Holter rhythm monitor was applied to all patients before VSD closure and to those in the control group. Holter rhythm monitoring was repeated at three months in the patient group. HRV parameters were measured using the Cardio Scan Premier 12® program. Frequency-domain (total power; very-low-frequency, low-frequency (LF), and high-frequency (HF) indices; and the LF/HF ratio) and time-domain (standard deviation of all RR intervals (SDNN), standard deviation of 5-min averages of RR intervals (SDANN), the SDNN index, percentage of the difference between adjacent RR intervals, and the square root of the mean of the sum of square differences between adjacent filtered RR intervals) parameters were assessed. RESULTS: Before the procedure, SDNN, SDANN, and total power values were lower in the patient group than in the control group; other parameters were similar in the two groups. No significant difference in the SDNN, SDANN, or total power was detected between the patient and control groups in the third month, indicating that autonomic control of patients' hearts became normal during the third postoperative month. No correlation was detected between any hemodynamic parameters and any time-domain or frequency-domain parameters before closure. CONCLUSION: This study showed that transcatheter closure of VSDs changed HRV parameters in pediatric patients.

[Evaluation of the Respiratory Viral Panel PCR Test Results Before and After COVID-19 Pandemic]. / COVID-19 Pandemisi Öncesi ve Sonrasinda Solunum Yolu Virüs Paneli PCR Test Sonuçlarinin Degerlendirilmesi.

During the ongoing Coronavirus disease-2019 (COVID-19) pandemic, infections caused by other respiratory viruses continue to be seen and constitute an important health problem. In this study, it was aimed to evaluate the frequencies of respiratory tract viruses detected by respiratory tract virus panel (Allplex Respiratory Panel, Seegene, South Korea) multiplex real-time PCR test in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pre-pandemic period, and in the first and second year of the pandemic. The distribution of viral agents between these three periods was also investigated. In addition, it was planned to investigate the frequency of coinfection with SARS-CoV-2 and other respiratory tract viruses during the pandemic. When the sum of the three periods were evaluated together, it was observed that at least one respiratory tract virus was detected in 13 802 (32.7%) of 42 174 samples. While at least one respiratory tract virus was detected in 8740 (54.6%) of 16 002 samples in the pre-pandemic period, at least one respiratory tract virus was detected in 1638 (9.4%) of 17 510 samples in the first year of the pandemic, and in 3424 (39.5%) of 8662 samples in the second year of the pandemic. In the first year of the pandemic, a statistically significant difference was observed that the number of viruses detected decreased due to closure measures and the use of personal protective equipment (p<0.001). It was determined that the frequency of the detection of respiratory tract viruses other than SARS-CoV-2 started to increase again and a statistically significant difference occurred in the third period when vaccination started and the transition to normalization began by gradually loosening the closure measures (p<0.001). Rhinovirus was the most frequently detected virus in all three periods of the study (First period: 16.5%; second period: 5.9%; third period: 16.5). More than one respiratory tract virus was detected simultaneously in 2061 (14.9%) of 13 802 samples, in which at least one respiratory tract virus was detected within the scope of the study. Rhinovirus (7.3%) took the first place among the viruses found in coinfection. In the second and third periods covering the pandemic period, it was observed that the SARS-CoV-2 PCR result was also positive in 177 (4.2%) of 4219 samples whose respiratory tract virus panel PCR results were positive and simultaneously had a SARS-CoV-2 PCR test request. Therefore, it was concluded that SARS-CoV-2 coinfection can be observed in the same patient with other respiratory tract viruses in respiratory tract samples. The addition of SARS-CoV-2 to the respiratory tract virus multiplex PCR panels currently in use will enable faster detection of such coinfections. It is thought that both the incidence of respiratory tract virus infections other than SARS-CoV-2 and the rate of coinfection with other respiratory tract viruses in SARS-CoV-2 infection may increase with the relaxation of the measures taken for the control of the pandemic. For this reason, the detection of viruses that cause respiratory tract infections from clinical samples with reliable and rapid methods will ensure the measures to be taken to protect public health without delay and thus contribute to the prevention of the spread of infections.

Effects of azithromycin on ventricular repolarization in children with COVID-19.

Introduction: Azithromycin is used to treat pediatric COVID-19 patients. It can also prolong the QT interval in adults. This study assessed the effects of azithromycin on ventricular repolarization in children with COVID-19. Method: The study prospectively enrolled children with COVID-19 who received azithromycin between July and August 2020. An electrocardiogram was performed before, one, three, and five days post-treatment. Using ImageJ®, the following parameters were measured: QT max, QT min, Tp-e max, and Tp-e min. The parameters QTc max, QTc min, Tp-ec max, Tp-ec min, QTcd, Tp-ecd, and the QTc/Tp-ec ratio were calculated using Bazett's formula. Results: The study included 105 pediatric patients (mean age 9.8±5.3 years). The pretreatment heart rate was higher than after treatment (before 92 [79-108]/min vs. Day 1 82 [69-108)]/min vs. Day 3 80 [68-92.2]/min vs. Day 5 81 [70-92]/min; p=0.05). Conclusion: Azithromycin does not affect the ventricular repolarization parameters on ECG in pediatric COVID-19 cases.

Introdução: A azitromicina (AZ) é utilizada no tratamento da COVID-19 em pediatria. Como este fármaco pode prolongar o intervalo QT nos adultos, este estudo avaliou os efeitos da AZ na repolarização ventricular de crianças com COVID-19. Método: Este estudo prospetivo incluiu crianças com COVID-19 que foram tratadas com AZ em julho-agosto 2020. Foi efetuado um eletrocardiograma (ECG) antes e um, 3 e 5 dias após o tratamento. Utilizando ImageJ ®, foram medidos os parâmetros seguintes: QT max, QT min, Tp-e max, e Tp-e min. Os parâmetros QTc min, Tp-ec max, Tp-ec min, QTcd, Tp-ecd e QTc/Tp-ec ratio foram calculados utilizando a fórmula Bazett. Resultados: O estudo incluiu 105 doentes pediátricos (idade média 9,8±5,3 anos). A frequência cardíaca no pré-tratamento foi mais elevada do que após o tratamento (antes 92 [79­108]/min versus dia 1 82 [69­108)]/min versus dia 3 80 [68­92,2]/min versus dia 5 81 [70­92]/min; p=0,05). Conclusão: A AZ não afeta os parâmetros de repolarização ventricular no ECG nos casos pediátricos da COVID-19.

GATA-4 Variants in Two Unrelated Cases with 46, XY Disorder of Sex Development and Review of the Literature

The genetic cause of 46, XY disorder of sex development (DSD) still cannot be determined in about half of the cases. GATA-4 haploinsufficiency is one of the rare causes of DSD in genetic males (46, XY). Twenty-two cases with 46, XY DSD due to GATA-4 haploinsufficiency (nine missense variant, two copy number variation) have been previously reported. In these cases, the phenotype may range from a mild undervirilization to complete female external genitalia. The haploinsufficiency may be caused by a sequence variant or copy number variation (8p23 deletion). The aim of this study was to present two unrelated patients with DSD due to GATA-4 variants and to review the phenotypic and genotypic characteristics of DSD cases related to GATA-4 deficiency.

The association of viral load and disease severity in children with COVID-19.

It is still not fully understood how to predict the future prognosis of patients at the diagnosis coronavirus disease 2019 (COVID-19) due to the wide clinical range of the disease. We aimed to evaluate whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load could predict the clinical course of pediatric patients. This study was conducted retrospectively with medical records of pediatric patients who were tested for SARS-CoV2 between April 12 and October 25, 2020 in the University of Health Sciences, Ankara Educating and Training Hospital and Hacettepe University Faculty of Medicine. We evaluated 518 pediatric patients diagnosed with COVID-19 and classified according to severity as asymptomatic (16.2%), mild (59.6%), moderate (20.2%), and critical/severe (3.9%) cases. We analyzed patients in four groups in terms of ages: <4, 5-9, 10-14, and 15-17 years. There was no statistically significant difference in terms of ∆Ct value among age groups, different gender and the existence of underlying diseases in each disease course. The ∆Ct values were relatively lower in the first 2 days of symptoms than after days in all groups. Our study has indicated that children with COVID-19 have similar amount of viral load in all disease courses irrespective of the age and underlying disease. It should be taken into account that, regardless of the severity of the disease, pediatric patients may have a role in the transmission chain.

Validity and reliability analysis of the Turkish version of pediatric nutritional risk score scale.

BACKGROUND/AIMS: We aimed to perform the validity and reliability analysis of the Turkish version of the Pediatric Nutritional Risk Score (PNRS). MATERIALS AND METHODS: The study group consisted of 149 patients aged between 1 month and 18 years who were admitted to the hospital for at least 48 h. The patients' age, gender, anthropometric measurements, length of stay, admission diagnosis, daily body weights, food consumption, and pain status were recorded. Backward and forward translations into Turkish were done. PNRS was performed by two different physicians. The consistency of the PNRS results was evaluated to determine the validity of PNRS. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Of all patients, 69 (46.3%) were female and 80 (53.7%) were male. The mean length of the stay was 7.3±4.0 days. The mean age of the patients was 51.9±63.6 months. The Kappa coefficient between the two physicians was 0.66. Weight loss was observed in 65.2% of the patients in the high-risk group and 25.4% in the low-risk group. The hospital malnutrition rate was 31.5%. A higher risk was identified in those with <50% food intake and more severe disease. The specificity, sensitivity, NPV, and PPV of PNRS were 82.1%, 77.8%, 92.0%, and 58.3%, respectively. CONCLUSION: A good consistency suggests that the Turkish validation was achieved successfully. The power of PNRS to discriminate the patients with moderate-low risk of developing malnutrition is higher than the patients with high risk. PNRS is considered a valid and reliable tool to establish the risk of malnutrition in the hospitalized patients.

Percutaneous ASD closure of children weighing less than 10 kg.

Background: Traditionally the procedure of percutaneous ASD closure is carried out in children weighing more than 15 kg. The aim of this study was to discuss the success, efficacy and safety of the percutaneous closure of symptomatic ASD in children weighing less than 10 kg.Material and methods: This study was performed in two centres. A total of 44 patients were included. Demographic and angiographic data of these patients were gathered retrospectively from patients' records. Main indications for ASD closure were: failure to thrive, recurrent respiratory infections, bronchopulmonary dysplasia and genetic syndromes.Results: Median weight of patients was 9.0(8.12-9.50) kg. Bodyweight of 22 patients was less than 3 percentiles. In the follow-up, this number was lowered to 9 patients at 12 months. Median age of patients was 18.0(12.0-285) months. Minimum age and weight of patients was 3 months and 4.5 kg, respectively. Median mean pulmonary pressure was 24.0(20.0-29.5). The values of median defect size were measured in Cath lab as 13.0(10.75-15.3) mm. Median device size was 13(9-15) mm. Defect size was evaluated according to body weight and body surface area. The ratio of weight per defect size was 0.65(0.54-0.84) also the ratio of body surface area per defect size was 0.032(0.028-0.04). The ratio of total septum per device diameter was 2.5(2.1-3.1). Types of devices used were Amplatzer Septal Occluder, Cera Flex Septal Occluder, Figulla Flex II Atrial Septal Occluder, Memopart Septal Occluder. All cases were closed successfully, but the device had to be retrieved in one patient after successful positioning because it was detected that device compressed the aorta. No major complications were seen.Conclusion: In the experienced centres, percutaneous ASD closure can be done effectively and safely in symptomatic children weighing less than 10 kg.

Percutaneous Ventricular Septal Defect Closure in Patients Under 1 Year of Age.

Untreated ventricular septal defect (VSD) is an important cause of congestive heart failure in early infancy. Growth is impaired in this population, and surgical closure is challenging because of congestion in the lungs, making infants prone to respiratory infection, and because of their poor nutritional status. The aim of this study is to share our experience with percutaneous VSD closure in patients under 1 year of age. Patients with hemodynamically significant left-to-right shunt, less than 1 year of age, and with VSD diameter ≤ 6 mm were retrospectively included in the study between December 2014 and January 2017. The median length of follow-up was 8.5 (4-14.2) months. Twelve patients from 2 to 12 months of age, with a median weight of 6.75 (5.4-8) kg, were included. The mean VSD diameter as measured by angiography from the left ventricle side was 4.7 ± 0.25 mm, and from the right ventricle side was 3.4 ± 1.1 mm. All were of a perimembranous type except three, which were muscular. All defects were closed with the Amplatzer Duct Occluder II (ADO II) or the ADO II-additional size. The mean fluoroscopy duration and total radiation dose were 22.6 ± 18.7 min and 1674 ± 851 cGy/min, respectively. No aortic regurgitation associated with device closure was seen in any of the patients. Complete atrioventricular block occurred in one patient 6 months after the procedure, and was treated with a permanent pacemaker. VSD closure is challenging, regardless of whether a surgical or percutaneous procedure is used. The risks are higher for children younger than 1 year with low body weight. Percutaneous closure, which carries similar risks but is less invasive than surgery, may be the preferred alternative in early infancy.

Is hypertension the fate of aortic coarctation patients treated with Cheatham Platinum (CP) stent?

AIM: The aim of this study is to address the presence of hypertension and risk for cardiovascular diseases in patients with Coarctation of the Aorta (CoA) who were treated with endovascular stent placement. METHODS: Twenty patients (mean age: 14.2 ± 3.9 years) who were treated with stent and 20 age- and sex-matched controls were included to the study. Structure and functions of left ventricle were assessed by echocardiography. Carotid intima media (CIM) thickness was measured by using sonography as a marker for detecting cardiovascular risk. As indirect marker of arterial stiffness, pulse wave velocity, and augmentation index were recorded by ambulatory blood pressure monitorization/arteriography device. RESULTS: By ambulatory blood pressure monitorization, 24 h and daytime systolic and mean arterial pressure values were found to be significantly higher in patient group. Based on percentile values, 15% and 5% of patients were pre-hypertensive and hypertensive, respectively. Pulse wave velocity and cardiac output values were found to be significantly higher than control group. CIM thickness was also found to be significantly higher in patient group when compared to controls. CONCLUSIONS: It was shown that hypertension incidence as demonstrated by ambulatory blood pressure monitorization and risk for cardiovascular diseases as indicated by CIM thickness and Pulse wave velocity were higher than those in healthy population even after CoA is corrected.

Mid-term results of percutaneous ventricular septal defect closure with Amplatzer Duct Occluder-II in children.

Aim The aim of this study was to share the mid-term results of percutaneous ventricular septal defect closure using Amplatzer Duct Occluder-II in children. BACKGROUND: Nowadays, percutaneous ventricular septal defect closure is accepted as an alternative to surgery, but so far no ideal device has been developed for this procedure. METHODS: In the study centre, between April, 2011 and October, 2016, the ventricular septal defect of 49 patients was closed percutaneously using the Amplatzer Duct Occluder-II device, and seven of them were <1 year old. RESULTS: The mean age of patients was 86.8±52.6 months. The mean weight of the patients was 24.3±16 kg. The mean diameter of the defect was 3.7±1.4 mm. Mean fluoroscopy time and total procedure time were 37±19.3 and 74.1±27 minutes, respectively. The types of ventricular septal defects were muscular in six patients, and were perimembranous in the rest of them. We did not face any major complications during the procedure, but one patient was admitted with a complete atrioventricular block in the 6th month of follow-up. The total follow-up period was 66 months. CONCLUSION: To our knowledge, our study includes the largest series of paediatric patients whose ventricular septal defect was closed using Amplatzer Duct Occluder-II percutaneously. When the complications during the 66-month follow-up period are taken into consideration, we can state that Amplatzer Duct Occluder-II is a safe and effective device, even in infants aged <1 year.