Why are some South African children with Down syndrome not being offered cardiac surgery?

About 1 in 1,000 children has Down syndrome. Extra chromosomal material results in a myriad of potential problems for the affected individual. About 40% of Down syndrome children will have cardiac abnormalities, ranging from the simple arterial duct to the complex atrioventricular septal defect. Virtually all these defects are amenable to surgical correction and extended survival is possible. In South Africa many of these children do not undergo cardiac surgery.

Diagnosis of haemodynamically significant patent ductus arteriosus in neonates-- is the ECG of diagnostic help?

The presence of a haemodynamically significant patent ductus arteriosis (PDA) in the premature newborn may contribute to the development of brochopulmonary dysplasia, intraventricular haemorrhage and necrotising enterocolitis. It is therefore essential that the diagnosis of such a PDA be made in time in order to intervene medically or surgically. Echocardiography is at present the prime diagnostic tool, but it is mainly available in tertiary hospitals. Chest roentgenography is of little diagnostic value especially in the presence of respiratory disease, which is often present in premature babies. Very little is known about the diagnostic value of the electrocardiogram (ECG) in premature babies. The aim of this study was to describe the standard 12-lead ECG findings in low-birth-weight babies with haemodynamically significant PDAs. Thirty-two babies with haemodynamically significant PDAs, as established by echocardiography, were included in the study. Standard 12-lead ECGs were done in all these babies. In 15 patients ECG abnormalities were found; only 22% had left atrial and left ventricular enlargement indicative of significant left-to-right shunting, while 78% had no ECG changes indicative of left-to-right shunting. In conclusion, the ECG cannot be used to identify haemodynamically significant PDAs.

Complete atrioventricular septal defect.

Complete atrioventricular septal defect (CAVSD) is known to be associated with Down syndrome (DS) and to be a major cause of infantile death in these patients. Recently several leading articles reported that complete surgical repair before 6 months of age is a relatively low-risk procedure leading to a dramatic improvement in outcome. Most surgical reviews, however, fail to describe their selection criteria and to include patients who die early in infancy or who are unfit for surgery for some or other reason. A retrospective descriptive study was done of all children with CAVSD treated over a period of 15 years from 1980 to 1994 at our institution. The aims were to describe the profile of children with CAVSD in our population, and to evaluate screening procedures and treatment received versus outcome. Thirty-three patients were included in the study, 25 with DS and 8 without. The basic skills of careful auscultation, interpretation of chest radiograph and electrocardiograms (ECGs) are all 100% sensitive in alerting the physician to this condition. Careful screening, especially of DS babies, is essential to ensure early optimal intervention. Echocardiography is the least invasive, most informative investigation to establish a definite diagnosis. The Rastelli anatomical classification is highly indicative of outcome. Children in the Rastelli C group showed a universally dismal prognosis. Digitalis and furosemide are still the mainstay of medical treatment. No additional benefit was observed with the limited introduction of angiotensin-converting enzyme (ACE) inhibitors. Complete repairs were undertaken earlier and more frequently in recent years, but limited resources had led to the majority of patients not receiving surgery at all. There was insufficient urgency to aim for early complete repair, and more than 20% of children died before even being considered for surgery. This study is the first in South Africa to describe our own patient population and to evaluate local practice. Adequate screening of babies (especially those with DS), with early referral for complete repair in the first 6 months of life, remains the goal of optimal management.

Congestive heart failure readmission.

Multiple hospital readmissions average between 21% and 27% in the United States yearly. Little is understood about what causes this rate and, more importantly, how readmission can be prevented. An integrative review examined 13 research articles in an attempt to identify specific factors that lead to readmission. Risk factors continually researched were dependency, patient age, stage of illness, hospital length of stay (LOS), prior hospitalization, care after discharge, and mobility status. Congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) were the medical conditions responsible for most readmissions. No single factor was found to universally predict readmission, but several were statistically significant. Because of the results of this review, a study was conducted to determine whether clients with a primary or secondary diagnosis of CHF who receive home health care and a systematic education program would be less likely to be readmitted to the hospital or have a shorter LOS if readmitted than home health clients who did not receive the education program.

Risk factors associated with multiple hospital readmissions.

The percentage of multiple hospital readmissions averages between 21% and 27% in the United States today. The reasons for this readmission rate and, more important, how readmissions can be prevented, are not clear. In this integrative review we examine 13 research articles in an attempt to identify specific factors leading to the readmission of medical patients. Risk factors continually researched throughout the articles were dependence, patient age, stage of illness, length of hospital stay, prior hospitalization, care after discharge, and mobility status. Congestive heart failure and chronic obstructive pulmonary disease were the medical conditions responsible for most readmissions. No single factor was found to universally predict readmission, although several items were found to be statistically significant.