Are arrhythmias in rheumatic mitral regurgitation common as in mitral valve prolapse in children ?

Rheumatic fever is a common cause of acquired heart disease in children and young adult throughout the developing world and the pancarditis caused by rheumatic fever may manifest by palpitations. Ventricular arrhythmias are a common feature in patients with mitral valve prolapse [MVP] and several factors have been identified in those patients who progress to sudden death, including severe mitral regurgitation. So could arrhythmias in children with rheumatic mitral regurgitation [MR] be as common as in patients with mitral valve prolapse? This study included 30 patients [pts] with isolated rheumatic mitral regurgitation with different grades [mild, moderate and severe mitral regurgitation] diagnosed by echocardiography [group I] compared to group II [control group], which included 30 healthy children with a normal heart confirmed by echocardiography. All the study population was subjected to the following: Full medical history and physical examination, laboratory investigations, twelve leads ECG, chest X-ray, echocardiography and Ambulatory twenty four hours ECG monitoring [Holter]. The total prevalence of arrhythmias detected by Holter monitoring in the studied patients and control group were 40% [12 pts] and 16.6% [5 pts] respectively, p value = 0.04. As regard the type of arrhythmias; sinus tachycardia occurred in 10 pts [33.3%] and 4 pts [13.3%] in group I and II respectively [p value > 0.05]. Infrequent premature atrial contractions [PACs] occurred in 2 pts [6.7%] in group I and one patient [3.3%] in group II [p value > 0.05]. The incidence of arrhythmias detected by Holter recording was insignificant with mild MR compared to the control group [p value = 0.4]. Thereafter, the prevalence of arrhythmias increased proportionally to the degree of MR. The occurrence of arrhythmias in pts with moderate and severe rheumatic MR was significantly higher as compared to the control group [p value = 0.02 and 0.009 -respectively]. The incidence of arrhythmias was not significantly higher in cases of rheumatic MR with active rheumatic fever [4 pts had arrhythmias out of 5 pts with rheumatic activity] than those with rheumatic MR without rheumatic activity [p value = 0.07]. The prevalence of arrhythmias in the patients studied in relation to the echocardiographic findings revealed a significantly higher incidence of arrhythmias in rheumatic MR with left atrial enlargement; eleven out of thirteen pts had sinus tachycardia and PACs [p value = 0.0001]. We conclude from this study that rheumatic mitral regurgitation in the pediatric age group is associated with sinus tachycardia and uncommonly with premature atrial contractions; no other arrhythmias were detected even in association with cardiac enlargement or active carditis. The incidence of arrhythmias in MVP is much more common than in rheumatic MR. Ventricular arrhythmias occurs in MVP, while it did not occur with rheumatic MR in our study. The incidence of arrhythmias in rheumatic MR is significantly related to the severity of mitral regurgitation

Duodenal injury after blunt abdominal trauma in children: experience with 22 cases

Introduction: The natural history and management of duodenal injuries in children are incompletely described. The aim of this study was to describe the relation between the mechanism of blunt trauma and the severity of duodenal injury, as well as evaluation of the diagnostic and treatment modules of blunt duodenal trauma [BDT] in order to improve the management of these injuries

Patients and Methods: A retrospective chart review was conducted on children presenting with history of abdominal trauma presenting over a period of 6 years. Only patients who were diagnosed with duodenal injury were included. The patients were divided according to their initial clinical presentation into 3 groups: group I [n=11] with evidence of peritonitis, group II [n-5] with abnormal abdominal findings and group III [n=6] with no significant abdominal findings

Results: Twenty-two patients were encountered. There were 15 males and 7 females, their age ranged from 6 months to 10 years. The mechanism of trauma was Road Traffic Accident [passenger or pedestrian] in 12 patients and Focal trauma to the abdomen in the remaining 10 patients. Time to initial exploration in the 17 patients with duodenal perforations was less than 8 hours from admission in 7 patients, from 8-24 hours in 7 patients, from 24- 48 hours in 2 patients and one patient was explored after 55 hours of admission. Complications were encountered in 2 patients after surgical repair of duodenal injuries. Two patients died, however the cause of death was unrelated to the duodenal trauma

Conclusion: Although duodenal trauma in children is uncommon, the physician examining a child with upper abdominal symptoms must have a high index of suspicion for duodenal injury even in the absence of history of trauma. The lethal potential of duodenal trauma relates to the severity of the trauma, associated injuries, and the adequacy as well as expedience of treatment

Cardiac changes in children with primary hypothyroidism

The heart is a major target organ for thyroid hormone action, and marked changes occur in cardiac function in patients with hypothyroidism. The hemodynamic changes typical of hypothyroidism are opposite to those of hyperthyroidism, but they are accompanied by fewer symptoms and signs. Thyroxine therapy reverses all the cardiovascular changes associated with hypothyroidism. This work was planned to evaluate prospectively the cardiac performance and structure in children with primary hypothyroidism by echocardiography before and after replacement therapy with thyroxine. Twenty one infants and children with untreated primary hypothyroidism were included. Twenty age and sex matched healthy controls were also included. All patients were subjected to complete physical examination, thyroid function tests, ECG and M-mode, 2-dimensional, pulsed and continuous wave Doppler examination before and 6 months after therapy. The results proved that following parameters were significantly higher in cases compared to their control subjects: LVDd[0. 56 +/- 2.2 VS-0.8 +/- 2, p=0.04], Ao [0.38 +/- 1.2 VS-0.67 +/- 1.1, p=0. 007], RPA [-.16 +/- 15 VS-2.5 +/- 0.7, p= 0.018] and LPA [1.13 +/- 2.3 VS -2.3 +/- 0.87, p=0.021]. By comparing the baseline echocardiographic parameters to those after 6 months of therapy, the following were observed: increased LVDd after therapy [0.56 +/- 2.2 VS 1.31 +/- 2, p=0.03]; diminished LV mass [0.32 +/- 1.6 VS -0.91 +/- 1.1, p=0.03]; diminished RVDd [0.82 +/- 0.8 vs 0.43 +/- 0.7, p=0.01]; significant improvement in all systolic function after therapy: EF% [71.6 +/- 6.5 VS 75 +/- 5.2, p=0.019], FS% [34.8 +/- 5.3 VS 39.3 +/- 5.1, p=0.008], VCF [1.32 +/- 0.27 VS 1.5 +/- 0.31, p=0.001], Aortic peak flow [0.95 +/- 0.2 VS 1.069 +/- 0.29, p=0.05] and pulmonary AT [0.149 +/- 0.13 VS 0.09 +/- 0.03, p=0. 047]. Moreover, the following parameters of diastolic function showed significant change at 6 month after therapy: mitral A[0.44 +/- 0.11 VS 0.61 +/- 0.28, p=0.02], mitral E/A [1.98 +/- 0.61 VS 1.46 +/- 0.49, p=0.006] and tricuspid E [0.58 +/- 0.13 VS 0.65 +/- 0.13, p=0.05]. The following echocaidiographic structural findings were also observed in our cases: PFO was found in 6 cases [28%] with a mean diameter 013 t 1.26mm; TR in 15 cases [71%], mean PG 15.71 +/- 7.6 mm Hg, PR in 11 cases [52%], mean PG 8.86 +/- 4.2 mm Hg, MR in 2 cases [0.09%, mean PG 14.5 +/- 6.3 mm Hg. None of our patients showed pericardial effusion. me duration of the illness was significantly correlated to base line Ao [p=0.001], LVDD [p=0.04] and RV p=0. 001]. Both base line FT3, FT4 showed significant correlations to LA [p= 0.04 and 0.016 respectively]. Seam triglycerides showed significant negative correlation to VCF [p=0. 009]. The dose of Ievothyroxin show significant negative correlation to RV [p=0. 04] and significant positive correlation to VCF [p=0. 03]. Meanwhile, the dose of L-thyroxin showed significant positive correlation to LV mass at 6 months [p= 0.04], and duration of illness showed significant positive correlation to RV [p=0. 02] and finally TSH at 6 months showed significant negative correlation to Ao at 6month after therapy [p=0. 04]

Conclusion: Evidence of alteration in cardiac systolic and diastolic functions is seen in children with primary hypothyroidism. These do improve with treatment. Structural cardiac anomalies could be demonstrated as an example of associated extra thyroidal anomalies. Classic teaching descriptions of ECG changes and pericardial effusion in advanced hypothyroidism were not seen