Brain abscess in cyanotic congenital heart disease: a preventable complication with heavy financial burden and poor outcome

To evaluate the financial burden and outcome of the children with brain abscess and underlying congenital cyanotic heart disease. To emphasize the need of early diagnosis and surgery of congenital cyanotic heart disease. Cross Sectional Descriptive Study. This study was conducted at the department of paediatric cardiology The Children's Hospital and The Institute of Child Health, Multan from February 2010 to January 2012. All the patients presenting with brain abscess and having underlying congenital heart disease were included in the study. All the patients underwent transthoracic echocardiography and computed tomography [CT] scan of the brain. Data was taken on a written proforma after proper consent. A total of 58 patients with cyanotic congenital heart disease presented with CNS manifestations including headache, fever, focal neurological signs, fits or altered sensorium during the study period. Out of these 24 turned out to have brain abscess. Multiple brain abscesses were found in 7 patients. All the patients were given broad spectrum IV antibiotics. 19 of the patients required surgical intervention. Repeat CT scan was performed in all the patients. Only 5 patients recovered without any neurological sequalae. 7 patients expired during hospital stay. All of the remaining 12 patients survived but with some permanent neurological deficit. IV antibiotics, supportive treatment, CT scan, other laboratory investigations and surgery, all have a lot of cost. Around 1500 to 2000 US [dollar sign], on an average, were spent by the government on one patient during hospital stay. The only way to avoid CNS complications of CCHD is early diagnosis and early surgical treatment. But unfortunately, in this country because of lake of paediatric cardiology services and deficiency of paediatric cardiac surgery centers, corrective surgery of congenital cyanotic heart disease is delayed. It increases the risk of brain abscess formation which in turn leads to excessive financial burden on government resources and also increases the risk of long term neurological sequalae. Establishment of more and more paediatric cardiac surgery centers in this country is urgently required

pattern of ventricular septal defects and the severity of associated pulmonary hypertension in our set-up

Ventricular Septal Defect [VSD] is commonest of all the congenital heart diseases. This is found as an isolated lesion as well as in association with other congenital cardiac lesions. The management and outcome of isolated VSD is not only dependent upon the size but also depends on the associated complications of ventricular septal defect [VSD]. Pulmonary hypertension is not only the most common complication but also the most important indication of surgery in our setup. To study the pattern of various types of ventricular septal defects [VSDs] and assessment of severity of associated pulmonary hypertension in our population. Cross sectional descriptive study. The study was conducted at the paediatric cardiology department of The Children Hospital and The Institute of Child Health Multan, from October 2009 to March 2011. All patients with ages between 1 day to 15 years presenting with isolated VSD during the study period were studied using 2-D, continuous wave Doppler and color Doppler transthoracic echocardiography. Out of 403 patients with isolated VSD, 288 were of perimembranous type [71.4%], 57 were of muscular type [14.2%], 19 were of doubly committed sub arterial [DCSA] type [4.7%] and 39 patients were having inlet VSD [9.7%]. The mean age was 2.4 years. Females were 137 [34.0%] and males were 266 [66.0%]. Pulmonary hypertension was present in 210 patients [52.1%]. Amongst these mild pulmonary hypertension was present in 86 [40.9%], moderate in 65 [30.9%] and severe pulmonary hypertension was present in 59 [28.1%]. Perimembranous [PM] VSD is the commonest type of ventricular septal defect presenting to our hospital. The incidence of pulmonary hypertension is very high [52.1%] and even severe pulmonary hypertension was found in about a quarter of the patients. This shows the degree of delay in surgery and the major reason is non availability of pediatric cardiac surgery centers in government setups

Efficacy of transcutaneous electric nerve stimulation [TENS] therapy in overactive non-neurogenic neurogenic bladder [Hinman's Syndrome]

To compare the outcome of the patients of overactive non-neurogenic neurogenic Bladder Syndrome with traditional treatment alone and traditional treatment plus Transcutaneous electrical nerve stimulation [TENS] therapy. Twenty eight patients of Hinmans syndrome [all below 12 years] were recruited for the study at The Children's Hospital and The Institute of Child Health Multan, from August 2008 to November 2010. It was a randomized controlled trial and individual patients were categorized as having mild moderate or severe disease, on the basis of Overactive Non-neurogenic neurogenic bladder symptom score [OABSS] scoring system. The patients with equal grades of severity were placed in control and study groups each comprising 14 patients. Group A was given traditional treatment while group B was treated with TENS therapy in addition to traditional treatment. Improvement was observed by OABSS and voiding diaries. After 12 weeks of treatment, the patients were re-evaluated for their symptoms and grade of severity of disease, t-test was applied to compare outcome between two groups and p < 0.05 was considered to be statistically significant. At the start of treatment, dribbling and increased frequency was observed in all 28 patients and urgency was noted in 22 patients [11 patients in each group]. At the completion of treatment after 12 weeks, dribbling was observed in 11[78.51%] vs. 3[21.4%] children in group A and B respectively. Frequency was reduced to 8[57.14%] in group A and 5[35.7%] in group B patients. Urgency was also reduced to 8[72.7%] in group A while 3[27.3%] in group B patients. No marked side affect were noted, except local skin irritation in some patients. Transcutaneous electrical nerve stimulation [TENS] Therapy is an effective and safe tool to improve the symptoms and quality of life of the patients with Hinman syndrome but still large scale studies with longer follow up are required

Type and severity of valvular involvement in pediatric rheumatic heart disease patients

To assess frequency and severity of type of valvular involvement in pediatric patients with Rheumatic Heart Disease. This descriptive study was conducted in the Department of Pediatric Cardiology Children Hospital Complex, Multan from April 2008 to April 2010. The data of all pediatric patients below 15 years of age undergoing detailed cardiac evaluation including ECG, X-Ray and Echocardiography were reviewed. Only new cases of Rheumatic Heart Disease were studied for type and severity of valvular involvement. The data was analyzed using SPSS version 13. A total of 2381 echocardiograms were performed during the study period. 190 [08%] patients were diagnosed as having Rheumatic Heart Disease. Mitral regurgitation was the commonest lesion: In 148 [77.9%] patients mitral regurgitation was found either alone [104, 54.7%] or in combination [44, 23.2%] with other lesions. In 50 [26.3%] patients aortic regurgitation was found either alone [06, 3.2%] or in combination [44, 23.2%] with other lesions. Mitral stenosis was found in only 14 [7.4%] patients. No patient had Rheumatic tricuspid or pulmonary valve. Amongst mitral regurgitation patients 54 [28.4%] had severe MR, 76 [40%] had moderate MR and 18 [9.5%] had mild MR. Amongst aortic regurgitation patients 06 [3.2%] had severe AR, 18 [9.5%] had moderate AR and 26 [13.7%] had mild AR. The commonest combination lesion was MR + AR which was found in 44 [23.2%] patients. The commonest valve involved in patients with Rheumatic Heart Disease was mitral valve followed by aortic valve. Regurgitant lesions are much more common in our younger age group patients as compared to the adult Rheumatic patients in whom mitral stenosis is usually the common lesion