Echocardiographic Findings in Children with Multisystem Inflammatory Syndrome from Initial Presentation to the First Years after Discharge.

OBJECTIVE: We aimed to evaluate clinical and echocardiographic features of the children diag- nosed with multisystem inflammatory syndrome related to severe acute respiratory syndrome coronavirus-2 infection and determine early and mid-term cardiovascular outcomes. MATERIALS AND METHODS: We retrospectively evaluated 38 children who were diagnosed with multisystem inflammatory syndrome in our hospital between November 2020 and November 2021. Cardiovascular evaluations were performed during hospitalization, at the first, the second, and the third months after discharge, and then cardiac evaluation was repeated at 3-month intervals until a median of 24 weeks (range: 9-56 weeks). RESULTS: The mean age of patients was 9.6 years and 25 patients had cardiovascular involve- ment. Echocardiography showed that there was left ventricular dysfunction in 11 cases and any coronary abnormalities in 11 cases on admission. Cardiovascular involvement was most fre- quently seen in patients older than 10 years and of male sex. Severe clinical courses occurred in half of them. The mortality rate was 2.6% during hospitalization. At discharge, complete recovery was achieved in 30 cases and partial recovery was seen in 6 cases; there were 1 case with ventricular dysfunction and 5 cases with coronary abnormalities. At the last polyclinic visit, there was no case with symptoms or myocardial dysfunction, there was only 1 case with persist- ing coronary aneurysms. CONCLUSION: Cardiovascular abnormalities in patients with multisystem inflammatory syndrome show rapid resolution within the first month. We recommend long-term follow-up evaluation for coronary arteries.

An investigation of bird strike cases in the aviation sector with a novel approach within the context of the principal-agent phenomenon: Bird strikes and insurance in the USA.

Bird strikes, a risk factor in the aviation industry, are a common problem in certain states of the USA, while they are extremely rare in other states. Similarly, the seasonal distribution of bird strikes is not proportional. This situation poses an unfair situation in the aviation insurance of airline companies in terms of routes taken. The current study, detecting a literature gap related to the principal-agent problem within the aviation sector, evaluates the possible differences in aviation companies' insurance costs, assuming bird strikes are spatially and temporally analyzed in the US, and airline companies are provided with complete information regarding bird-strikes. In this research, QGIS software served in spatial model mappings. In terms of the threshold value, the study results show that making bird-strike insurance aircraft in twenty-one states which were below the threshold value increased the aviation costs of these airline companies, while in the remaining twenty-nine states, non-insurance raised the cost. In this context, as of 2022, it has been determined that not paying an extra premium for bird strikes in twenty-one states below the threshold value will create efficiency, while expending an above-average insurance premium in twenty-nine states and the District of Columbia above the threshold value will create efficiency. The research seeks to answer the following question: Is it fair for airlines operating on routes with low or high bird strike risks to pay the same amount of insurance cost?

"Triangular QRS-ST-T waveform ECG pattern" during SARS-CoV-2 infection in a paediatric case with multiple comorbidities.

Triangular QRS-ST-T waveform electrocardiography pattern, so-called "shark fin sign," is a rare and highly mortal electrocardiography finding, which usually occurs in adult patients with coronary occlusion. Here, we reported the first paediatric case occurring in a striking "triangular waveform electrocardiography pattern" due to myocarditis during COVID-19 infection.

The serial changes in myocardial functions after paediatric haematopoietic stem cell transplantation.

The aim of this study is to evaluate the changes in myocardial functions in children who underwent haematopoietic stem cell transplantation along with associated chemotherapy. Additionally, we evaluated the effect of baseline echocardiographic parameters on mortality. We evaluated 39 patients (mean age 7.4 years) who underwent haematopoietic stem cell transplantation owing to non-malignant disease. The control group included 39 healthy children who had normal cardiac findings. The myocardial functions were evaluated in all subjects by conventional echocardiography and tissue Doppler echocardiography before haematopoietic stem cell transplantation and in the 1st, 3rd, 6th, and 12th month after haematopoietic stem cell transplantation. All patients had normal left ventricular ejection fraction before haematopoietic stem cell transplantation, except one case. Before haematopoietic stem cell transplantation, the patient group had significantly greater mean pulmonary artery pressure and lower tricuspid valve annular plane excursion rate. Baseline E' velocities for mitral lateral annuli, septum, and tricuspid lateral annuli were lower in the patient group than the control group. The E' velocities for the left ventricle decreased in the patient group after haematopoietic stem cell transplantation, and then returned to baseline levels at the 6 months. E' and S' velocities for tricuspid lateral annuli also decreased after haematopoietic stem cell transplantation and were still depressed in the first year after haematopoietic stem cell transplantation. Baseline E' velocity for septum was significantly lower in patients who died after haematopoietic stem cell transplantation than patients who survived (p = 0.009). Subclinical impairment in both ventricular functions was observed after haematopoietic stem cell transplantation and the right ventricular functions were affected for longer periods than left ventricle after haematopoietic stem cell transplantation. The myocardial functions should be monitored after the first year of haematopoietic stem cell transplantation.

A rare complication of Behçet's disease in a 12-year-old girl: a large intracardiac thrombosis.

Behcet's disease is a multi-systemic inflammatory disease with a clinical spectrum as a triple complex of recurrent oral, genital ulcers, and uveitis. Cardiac involvement in patients with Behcet's disease is extremely rare and often associated with poor prognosis. Behcet's disease should be considered in the differential diagnosis of right ventricular mass especially in young adults, even there is no typical clinical features of Behcet's disease. In this case, a 12-year-old girl who admitted with chest pain and haemoptysis and then was diagnosed with intracardiac thrombus related to Behcet's disease during follow-up was described.

A newborn with aortico-left ventricular tunnel mimicking sinus of valsalva aneurysm.

Aortico-left ventricular tunnel (ALVT) is a rare congenital cardiac anomaly and constitutes less than 0.1% of all congenital cardiac defects (1). ALVT is described as an abnormal connection between the ascending aorta and the left ventricle which originates commonly above the right sinus of valsalva. Most patients are diagnosed with an ALVT during early infancy (2). Although transthoracic echocardiography (TTEAQ5) is more effective in diagnosis of ALVT, misdiagnosis rate was 17.1% (3). Sinus of valsalva aneurysm (SVA) is frequently confused with ALVT (3). We report a term female newborn with SVA in echocardiographic examination, but in surgery, she was diagnosed with ALVT.

Effects of Adrenocorticotropic Hormone Treatment on Heart Muscle in Patients with Infantile Spasm.

Background and aim Infantile spasm (IS) is a common epileptic syndrome of childhood epilepsies. The most effective treatment for IS is adrenocorticotropic hormone (ACTH). We hypothesized that ACTH treatment might change myocardial systolic and diastolic performance and cause cardiovascular side effects. This study aims to evaluate the effects of ACTH treatment on the heart muscle in IS patients. Materials and methods Eighteen newly diagnosed patients with IS participated in the study. ACTH (Synacthen® Depot) administered for two months in a total of 18 doses. A twelve-channel-surface electrocardiogram (ECG) and echocardiography performed in all patients before ACTH treatment, the second month after ACTH treatment (end of treatment), and two months later (after treatment). The systolic and diastolic myocardial functions were assessed by conventional and tissue Doppler imaging (TDI). Results The mean age of the patients was 8.1 months, and the patient group consisted of five female and 13 male subjects. None of the patients had clinically significant arrhythmia during treatment. After treatment, the mean heart rates of the patients significantly decreased (p=0.02), the systolic and diastolic blood pressures of patients did not change. We observed mild septal hypertrophy and an increase in the left ventricle mass index with ACTH treatment. Septal hypertrophy did not show progression until the fourth month after treatment. After ACTH treatment, patients had higher left ventricular myocardial performance index and lower E' and A' values at the mitral lateral annuli, however, these values didn't statistically significant from pretreatment values. Conclusion The low dose and short duration ACTH treatment in IS patients may cause subclinical myocardial hypertrophy. ACTH treatment has no significant side effects on cardiac functions.

Heart rate variability in juvenile systemic lupus erythematosus patients.

Basaran Ö, Çetin II, Aydin F, Uncu N, Çakar N, Ekici F, Çelikel Acar B. Heart rate variability in juvenile systemic lupus erythematosus patients. Turk J Pediatr 2019; 61: 733-740. Although neurological involvement has been well recognized in patients with systemic lupus erythematosus (SLE), autonomic nervous system (ANS) involvement has rarely been studied, and has shown conflicting results. The aim of this study was to evaluate the ANS functions by using heart rate variability (HRV) in juvenile patients with SLE. Sixteen juvenile-onset SLE patients and 16 healthy controls were enrolled in the study. All participants underwent 24-hour Holter electrocardiogram monitoring and HRV indices were assessed. The SLE disease activity index (SLEDAI) score was used to assess the disease activity. We analyzed the correlation between disease duration, the SLEDAI score, and the HRV domains. Overall HRV was diminished in patients with SLE compared to controls. There were negative correlations between day and night RMSSD (root-mean-square of the successive normal sinus NN interval differences) and PNN50 (percentage of successive normal sinus NN intervals > 50 ms) values, and SLEDAI (r= -0.588 p=0.017; r= - 0.607 p= 0.013; r= -0.498 p=0.049; r= -0.597 p=0.015, respectively). There were positive correlations between both day and night LF/HF values and SLEDAI (r=0.766 p=0.001; r=0.635 p=0.008, respectively). The results suggest that autonomic dysfunction exists in juvenile patients with SLE. As these children are at increased risk for cardiovascular disease, they need to be assessed for the development of autonomic dysfunction.

Effects of vagus nerve stimulation on heart rate variability in children with epilepsy.

PURPOSE: The aim of this study was to evaluate the effects of vagus nerve stimulation (VNS) on heart rate variability (HRV) in children with epilepsy. METHODS: The subgroups of HRV, namely time domain (Standard deviation of NN interval (SDNN), SDNN index, Standard deviation of the averages of NN intervals (SDANN), Root mean square of successive differences (RMMSD), Adjacent NN intervals differing by more than 50 ms in the entire recording divided by the total number of all NN intervals (PNN50), triangular index) and frequency domain (Low-frequency (LF), High-frequency (HF), LF/HF), were investigated in 20 pediatric patients before and after 6 and 12months of VNS treatment during day and night by comparing their data with those of 20 control subjects. In addition, subgroups of age, epilepsy duration and localization, and antiepileptic drugs (AEDs) were also evaluated if they had further effects on basal HRV levels. RESULTS: Increased heart rates (HRs); decreased SDNN, SDANN, RMMSD, and PNN50; and increased LF/HF ratios were identified before VNS therapy (p<0.05). Even though remarkable improvement was seen after 6months of VNS treatment (p<0.05), no further changes were observed in 12-month compared with 6-month levels (p>0.05) in all parameters, still even significantly lower than those of controls (p<0.05). Longer duration of epilepsy and localization of epileptic focus, such as in the temporal lobe, were also found to further contribute to diminished basal HRV levels (p<0.05). CONCLUSION: The cardiovascular system is under deep sympathetic influence in children with epilepsy. Although VNS seems to provide a substantial improvement by achieving increased parasympathetic effects in short-term therapy, the levels were still lower than those of healthy children after either short- or long-term therapy. Therefore, impaired cardiovascular autonomic regulation may be associated with the epileptic process itself as well as with the contribution of some additional factors. Overall, different aspects such as age, epilepsy duration, epileptic focus, seizure frequency, and AEDs should also be considered for their further possible effects on HRV during VNS therapy.

The pre-participation screening in young athletes: which protocol do we need exactly?

The aim was to assess the utility and feasibility of a comprehensive cardiac screening protocol in young athletes before participation in sports. A total of 380 athletes referring before participation in sports, between April, 2014 and April, 2015, were included in this study. The mean age was 12.4 years. A screening protocol has been applied to all, including personal and family history, physical examination, 12-lead electrocardiography, transthoracic echocardiography, 24-hour rhythm Holter analysis, and treadmill exercise test. The most frequent complaints were chest pain in 19 (5%), dyspnoea in 13 (3.4%), and dizziness and fainting in five patients (1.3%) on exercise. There was sudden death and arrhythmia in 41 patients (10.7%) owing to family history. Heart murmur was present in 20 (5.2%) and hypertension in 10 patients (2.6%) on physical examination. The 12-lead electrocardiography was abnormal in 9 patients (2.4%). The findings of transthoracic echocardiography were insignificant in 47 patients (12.3%) and in five patients (1.3%) a haemodynamically important condition was detected. The 24-hour rhythm Holter analysis was abnormal in six patients (1.5%). There were significant ST changes in two patients (0.5%) on treadmill exercise test with normal findings on myocardial perfusion scans. No significant relation was present between findings of screening protocol and transthoracic echocardiography, 24-hour rhythm Holter analysis, or treadmill exercise test results. Pre-participation screening in young athletes should consist of a targeted personal history, family history, physical examination, and 12-lead electrocardiography. Other tests should be applied only if the screening indicates the presence of a cardiovascular disease.

Premature Coronary Artery Disease due to Homozygous Familial Hypercholesterolemia in a 12-Year-Old Girl.

BACKGROUND: Homozygous familial hypercholesterolemia is a rare inherited metabolic disease caused by low-density lipoprotein receptor abnormality. Patients with homozygous familial hypercholesterolemia have an increased risk of cardiovascular complication that usually occurs in the first decade of life. Here, we report a 12-year-old girl with an unpredicted presentation for coronary artery disease and found to have homozygous familial hypercholesterolemia. CASE REPORT: A 12-year-old girl was admitted to our unit with syncope. Chest X-ray showed bilateral diffuse pneumonic consolidation and mild cardiomegaly. We detected stable ST depression by electrocardiography. Echocardiography showed normal systolic functions. Troponin-1 levels were high (66 mcg/dL, upper limit: 0.04 mcg/dL). Influenza A virus DNA was detected by the respiratory viral panel. After her successful treatment for acute pneumonia and myocarditis due to Influenza A virus, her syncope attacks persisted. Marked ST elevation was observed during exercise electrocardiography. Coronary angiography showed severe occlusions in the coronary arteries. High serum levels of total cholesterol (756 mg/dL) and low-density lipoprotein-C (556 mg/dL) were noticed. She had no tendon xanthomas. Medical histories revealed that her family members were diagnosed with heterozygous familial hypercholesterolemia. A coronary bypass surgery was performed. Statin and ezetimibe treatments were started. We also planned lipid apheresis. CONCLUSION: Children with homozygous familial hypercholesterolemia may present with symptoms of premature coronary heart disease requiring a routine lipid test and careful anamnesis.

Elasticity of ascending aorta and left ventricular myocardial functions in children with bicuspid aortic valve.

BACKGROUND: The aim of the study was to determine the aortic elasticity parameters (EPs) and myocardial function in children with bicuspid aortic valve (BAV). Additionally, we evaluated the effect of aortic leaflet phenotype (ALP) and aortic dilatation on elasticity parameters. METHODS: Sixty-two children diagnosed with isolated BAV (mean age 9.3 years old; patient group) and 63 healthy children (control group) have been evaluated for this study. Patient group was divided into three age subgroups: between 0-6, 7-11 and 12-17 age intervals. Distensibility (DI) and stiffness index (SI) of ascending aorta were calculated by M-mode echocardiographic data. The myocardial functions were evaluated by tissue Doppler echocardiography. RESULTS: Patient group exhibited significantly lower DI and higher SI than control group (SI: 3.8 ± 1.7 vs 2.4 ± 0.8, P < .0001). The aortic elasticity indexes in patient group with different age subgroups were different from those in control subgroups. Patient group had significantly lower E' velocity at mitral lateral annulus and septum than control group (P < .017 and P < .001). There was no statistically significant correlation between E' velocities and DI/SI values. We, however, found a weak correlation between septal E' velocities and strain values (r = .255, P = .046). EP did not show statistically significant difference with regard to ALP and presence of aortic dilatation. CONCLUSION: Abnormality of aortic elasticity and myocardial functions can be detected in children with BAV from infantile to adolescent. Myocardial functions are not related to SI and DI. We considered the possibility of intrinsic aortic wall abnormality in children with BAV.

Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care units (PICUs): A prospective study.

OBJECTIVE: To determine the indication and necessity of echocardiographic assessment and therapeutic interventions in critically ill children. METHODS: A total of 140 children, including 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) children, who were admitted consecutively from March to August 2013 were evaluated prospectively. Data regarding the indication for echocardiography and therapeutic approaches used were documented. For evaluating disease severity, the Pediatric Risk of Mortality Score III (PRISM) was ascertained. The correlation between PRISM score and the requirement of echocardiographic evaluations were analyzed. RESULTS: Patients ages were between 45 days to 18 years. The male-to-female ratio was 1.33. In 35.4% patients who underwent echocardiographic evaluation, no definitive alteration occurred in treatment approach, whereas in the remaining 64.6% patients, decisive or supplemental information was gathered. Echocardiography was indicated in 88% MV children and 46.2% SB children. Echocardiographic evaluation was necessary in MV children and there was a positive correlation between the PRISM score and the requirement of echocardiographic assessment (p<0.001). CONCLUSION: Echocardiographic evaluation is an invaluable tool especially in MV children and the requirement of echocardiographic assessment increases according to clinical severity. Basic training for intensivists in this procedure is crucial and needs to be improved and supported in critically ill.

Assessment of tumors in children with tuberous sclerosis: a single centre's experience.

AIM: As a result of mutations in TSC1 (9q34) and TSC2 (16p13.3) tumor supressor genes, the mammalian target of the rapamycin (mTor) signaling pathway is overactivated in patients with tuberous sclerosis. Abnormal cell proliferation and differentiation is responsible for the growth several different tumors. The aim of this study was to review tumors in our patients with tuberous sclerosis. MATERIAL AND METHODS: Thirty-six patients with tuberous sclerosis were reviewed retrospectively in terms of age, sex, family history, clinical findings, presence of tumors, and treatments. RESULTS: Our study included 36 patients (18/18:M/F) aged between two days and 17 years with a median age of 6 years. There were hypopigmented spots in 30 patients, seizures in 28 patients, and a family history in 11 patients. Tumors related to tuberous sclerosis were renal angiomyolipomas in 21 patients, cardiac rhabdomyomas in 11, subependymal giant cell astrocytomas in seven, and non renal hamartoma in one patient. Everolimus treatment was used in only two patients because of hemodynamic instability. CONCLUSIONS: Tuberous sclerosis is a multisystemic disease characterized by the presence of various benign tumors and neurologic disorders. Renal angiomyolipomas, cardiac rhabdomyomas, and subependymal giant cell astrocytomas are commonly observed in patients with tuberous sclerosis. mTOR inhibitors such as everolimus and sirolimus have been increasingly used in the treatment of these tumors. However, the duration and optimal dose of mTOR inhibitors is still controversial and should be used in selected cases.

Brugada-Phenocopy Induced by Propafenone Overdose and Successful Treatment: A Case Report.

BACKGROUND: Brugada syndrome is an inherited arrhythmogenic disease that may cause sudden cardiac death due to ventricular fibrillation in young adults. Brugada syndrome caused by propafenone intoxication has been noted rarely in the literature. We report a rare case, Brugada phenocopy due to propafenone intoxication and its treatment. CASE REPORT: A 15-year-old girl having a seizure was brought to the emergency room. She took 1.5 g propafenone (Rythmol, Abbott, Chicago, IL, USA) for suicidal intention. She had metabolic acidosis. Long QRS interval and ST elevation in leads V1 through V3 were seen on electrocardiography. After bicarbonate infusion for 4 hours, haemodynamic and neurologic findings were recovered, and all electrocardiography abnormalities disappeared. The Brugada-like electrocardiography pattern was not recognized in her surface and 24-hour Holter electrocardiography at follow-up. Ajmaline challenge test was negative 2 weeks later. CONCLUSION: Absence of symptoms and documented ventricular tachycardia, negative challenge test, and a negative family history demonstrated that the Brugada phenocopy was a transient finding in this case and related to propafenone intoxication.

Assessment of left ventricular functions and myocardial iron load with tissue Doppler and speckle tracking echocardiography and T2* MRI in patients with ß-thalassemia major.

BACKGROUND: The purpose of this study is to determine early myocardial dysfunction in ß-thalassemia major (BTM) patients. Where the myocardial dysfunction cannot be detected by conventional echocardiography, it could be detected by tissue Doppler imaging (TDI) or speckle tracking echocardiography (STE). METHODS: In this study, we analyzed 60 individuals, 30 of whom were BTM patients and the other 30 of whom were the control group. T2* magnetic resonance imaging (MRI) was used to measure cardiac iron deposition. The myocardial functions were evaluated by conventional echocardiography, TDI and STE. RESULTS: When basal lateral left ventricular and basal septal wall TDI values were compared between the patient group and control group, only isovolumic contraction time values were significantly longer in the patients. The global circumferential strain was significantly lower in the patients. When evaluated as segmental, longitudinal strain values of basal inferoseptum and circumferential strain values of anteroseptum, anterior, and inferolateral segments were significantly lower in the patients. In the patients, global longitudinal and circumferential strains in the group who had pathological T2* values were significantly lower than the group who did not. In addition, circumferential strain values in anteroseptum, anterolateral, inferior, and inferoseptum segments were significantly lower in the patients with T2* values<20 ms than those with T2* values≥20 ms. CONCLUSION: Although T2* MRI is the most sensitive test detecting myocardial iron load, TDI and STE can be used for screening myocardial dysfunction. The abnormal strain values, especially circumferential, may be detected as the first finding of abnormal iron load and related to T2* values.

The association of consumptive hypothyroidism secondary to hepatic hemangioma and severe heart failure in infancy.

Although hemangiomas are the most common vascular tumors of the liver in infancy, data regarding hypothyroidism and heart failure related to hepatic hemangiomas are limited. Here, we present a 15- day -old girl who presented with prolonged jaundice at the age of 15 days. Because her TSH level was found to be 74 µIU/mL, she was initially diagnosed with congenital hypothyroidism and L-Thyroxine replacement therapy was initiated. On follow-up examination performed two months later, it was observed that her TSH level was not suppressed and a mass was noticed in the right upper abdomen on physical examination. Abdominal ultrasonography revealed multiple masses with sizes of about 3-3,5 cm covering the whole liver. When evaluated with clinical and radiological appearance, oral methylprednisolone at a dose of 5 mg/kg/day and propranolol at a dose of 2 mg/kg were initiated with a diagnosis of hepatic hemagioma/hemangioendothelioma. Consumptive hypothyroidism due to hepatic hemangioma and congestive heart failure were considered in the patient who had findings of heart failure. The dose of L-Thyroxine was increased 2-fold. The patient received intensive care treatment for severe heart failure. Because his findings resolved, he was started to be followed up with propranolol, steroid and L-Thyroxine treatment.

Decreased Deformation in Asymptomatic Children with Isolated Left Ventricular Non-compaction and Normal Ejection Fraction.

Echocardiography is the mainstay of screening and disease surveillance in isolated left ventricular non-compaction (iLVNC). The aim of our study is to determine the early regional and global myocardial functional changes and whether the myocardial changes that cannot be detected by conventional echocardiography could be detected by tissue Doppler imaging (TDI) or two-dimensional speckle-tracking echocardiography (STE) in iLVNC cases without symptoms. Longitudinal and circumferential strain (S) and strain rates (SR) as determined by STE in 20 children aged 12.1 ± 3.3 years was compared with those in 20 controls. All children underwent echocardiographic assessment using two-dimensional, tissue Doppler and speckle-tracking echocardiography. iLVNC patients who had normal systolic function by ejection and shortening fractions were included in this study. According to the TDI in all three segments [the non-compacted (NC), neighboring NC (NNC) and compacted (C) segments], isovolumic contraction time, isovolumic relaxation time and myocardial performance index values were significantly higher, while ejection time were significantly lower in the iLVNC group. According to STE in two segments (NC and NNC-segments) longitudinal S and SR values and also circumferential S and SR values were significantly lower in the iLVNC group compared with the control group; whereas, in the global measurements both longitudinal and circumferential S and SR values in all three segments were significantly lower in the iLVNC group compared with the control group. We believe that TDI and STE that evaluates myocardial deformation can be used for the detection of early myocardial dysfunction in the iLVNC patients who are subclinical and whose left ventricular functions were detected as normal by conventional methods with normal ejection and shortening fractions.

The efficacy and safety of naproxen in acute rheumatic fever: The comparative results of 11-year experience with acetylsalicylic acid and naproxen.

The objective was to compare the efficacy and safety of naproxen (NXN) to acetylsalicylic acid (ASA) in the treatment of acute rheumatic fever (ARF). The data of 338 children were retrospectively analyzed. The patients were grouped according to joint and valve involvement and also drug chosen [methyl prednisolone (mPSL), ASA or NXN]. The treatment results and adverse events in each group were compared. The mean age was 10.3 years and the median follow-up was 62 months. Median time for normalization of acute phase reactants was 1 week in patients given steroids and 2 weeks in patients given ASA or NXN. ASA was replaced with NXN in 18 patients (10.2%) due to hepatic toxicity. The rate of rebound, recurrence and the prevalence of rheumatic valve disease were not different in patients given NXN, ASA or mPSL. In conclusion, NXN is a safe and effective alternative to ASA in the treatment of ARF in children.