Accuracy of Whole Blood Cardiac Troponin I in the Diagnosis of Childhood Heart Failure at the University College Hospital, Ibadan.

OBJECTIVE: To determine the accuracy of cardiac troponin I (cTnI), a marker of myocardial cell injury or necrosis, in correctly identifying heart failure in children. PATIENTS, MATERIALS, AND METHODS: This was a crosssectional study in which 45 children aged 12 years or below admitted into the paediatric wards of the University College Hospital, Ibadan, who, on evaluation with the Ibadan Childhood Heart Failure Index (ICHFI) had a score of ≥ 3, were consecutively recruited. Forty-five age- and sex-matched apparently healthy children with ICHFI score of <3 were similarly evaluated as controls. Demographic, clinical data and cTnI values were documented. Statistical analysis was done using IBM SPSS version 23. RESULTS: There was a strong positive correlation (0.592) between the whole blood cTnI values and ICHFI scores (rs = 0.592, P = 0.000). At a cut-off value of 0.07ng/ml, the whole blood cTnI had a sensitivity of 26.7%, specificity of 97.8%, a positive predictive value of 92.8% and a negative predictive value of 57.1%. The receiver operating characteristic curve plotted had an AUC of 0.800 at the 95% CI, 0.704 - 0.896; P < 0.001. CONCLUSION: Whole blood cTnI level is elevated in children in heart failure and may predict severity of the condition. Whole blood cTnI was found to be an accurate tool for the exclusion of heart failure in children and is therefore recommended for use in children with suspected heart failure for its rapid diagnosis.

OBJECTIF: Déterminer la précision de la troponine cardiaque I (cTnI), un marqueur de lésion ou de nécrose des cellules myocardiques, dans l'identification correcte de l'insuffisance cardiaque chez les enfants. PATIENTS, MATÉRIEL ET MÉTHODE: Il s'agit d'une étude transversale dans laquelle 45 enfants âgés de 12 ans ou moins admis dans les services pédiatriques de University College Hospital, Ibadan, qui, après évaluation avec Ibadan Childhood Heart Failure Index (ICHFI), avaient un score ≥ 3, ont été recrutés consécutivement. Quarante-cinq enfants apparemment sains, appariés selon l'âge et le sexe, avec un score ICHFI de <3 ont été évalués de la même manière en tant que témoins. Les données démographiques, cliniques et les valeurs de cTnI ont été documentées. L'analyse statistique a été réalisée à l'aide d'IBM SPSS version 23. RÉSULTATS: Il existe une forte corrélation positive (0,592) entre les valeurs de cTnI dans le sang total et les scores ICHFI (rs = 0,592, P = 0,000). À une valeur seuil de 0,07 ng/ml, le cTnI du sang total avait une sensibilité de 26,7 %, une spécificité de 97,8 %, une valeur prédictive positive de 92,8 % et une valeur prédictive négative de 57,1 %. La courbe caractéristique du récepteur tracée avait une AUC de 0,800 à l'IC de 95 %, 0,704 - 0,896 ; P < 0,001. CONCLUSION: Le taux de cTnI dans le sang total est élevé chez les enfants souffrant d'insuffisance cardiaque et peut prédire la gravité de la maladie. Le taux de cTnI dans le sang total s'est avéré être un outil précis pour l'exclusion de l'insuffisance cardiaque chez les enfants et il est donc recommandé de l'utiliser chez les enfants suspectés d'insuffisance cardiaque pour un diagnostic rapide de l'insuffisance cardiaque. Mots clés: Troponine cardiaque I, Insuffisance cardiaque chez l'Enfant, Ibadan.

The Challenges of Managing Congenital Heart Diseases in Africa.

EDITORIAL.

Diagnostic Accuracy of a Clinical Scoring Scheme in Childhood Heart Failure.

BACKGROUND: Heart failure remains a major health problem. But its early diagnosis remains a significant challenge especially among the Paediatric population. A standardized highly sensitive and specific clinical basis of diagnosis requiring no sophisticated equipment readily elicitable at the patients beside at presentation is required. OBJECTIVE: The study set out to determine the accuracy of a clinical scoring scheme for the diagnosis of heart failure in infants in Ibadan, Nigeria, using B-type natriuretic peptide (BNP) as gold standard. METHODOLOGY: Forty-five consecutive infants admitted into the Paediatric wards of the University College Hospital and the Adeoyo Maternity Teaching Hospital in Ibadan, Nigeria were evaluated with the Ibadan Childhood Heart Failure Index (ICHFI) and those with clinical score of > 3 were recruited. Their plasma BNP levels and those of 45 age-matched controls were also measured. RESULTS: There was a strong positive correlation (0.920) between the ICHFI scores and plasma BNP values (rs = 0.920, P = 0.000). At a cut-off score of 2, the ICHFI has a sensitivity of 97.6%, specificity of 89.8%, a positive predictive value of 88.9% and a negative predictive value of 97.8%. The receiver operating characteristic curve plotted had an AUC of 0.978 at the 95% CI, 0.951-1.000; P < 0.001. CONCLUSION: The ICHFI was found to be an accurate tool for the diagnosis of heart failure in infants and it is therefore recommended for use in primary care and resource challenged settings for the rapid diagnosis, grading of the severity of heart failure and monitoring of treatment.

Acquired ventricular septal defect: a rare sequel of blunt chest trauma in a 7-year-old boy.

Ventricular septal defect (VSD) is the most common congenital cardiac lesion encountered worldwide. Only very rarely is it acquired, and causation through blunt injury in a child is extremely rare. A previously healthy 7-year-old boy suffered blunt chest trauma while at play. He presented 11 days later with features of acute congestive cardiac failure. Two-dimensional echocardiographic examination revealed a mid-muscular VSD. The connection between the defect and the trauma was not initially appreciated. Facilities for required urgent open-heart surgery were not available. Cardiac failure was refractory to anti-failure therapy. His clinical condition steadily worsened, and he succumbed after 20 days on admission. We conclude that a diagnosis of traumatic VSD, though rare, should be considered in any previously well child presenting in acute congestive cardiac failure following blunt trauma to the chest. Any such patient should undergo careful echocardiographic evaluation. There is an urgent need for facilities for open-heart surgery to be more readily available and accessible in Nigeria.

Transcatheter closure of patent ductus arteriosus and atrial septal defect without on-site surgical backup: a two-year experience in an African community.

Congenital heart disease contributes significantly to the health burden of children in Nigeria. Interventions for congenital heart disease have been available in the developed world since the first report on device closure of patent ductus arteriosus (PDA) in 1967 by Porstmann. However, this did not start in Nigeria until October 2010. This study aimed to document the profiles of the patients who had undergone interventions for congenital heart diseases since the availability of the procedure, the challenges encountered, and the prospects associated with the interventions at the study site. All the patients referred to undergo interventions for congenital heart disease at the study center between October 2010 and 2012 were studied. The profile of the patient, including diagnosis at referral, indication for interventions, and interventions performed, were documented. The patients ranged in age from 3 to 62 years (mean age, 13.54 ± 17.7 years), and the male-to-female ratio was 1:3. The diagnosis at referral included PDA in 10 (83 %) of the 12 patients and secundum atrial septal defect in 2 patients (17 %). They all had transcatheter closure of the defects. Interventional procedures for congenital heart diseases currently are available locally, but the high degree of manpower training required, the cost, and the local availability of consumables are major factors limiting their use. Regional and international collaboration could be mutually beneficial.

Normal Ultrasonographic Dimensions of the Liver in Neonates in South-West Nigeria.

BACKGROUND: Ultrasound (US) is first choice of imaging in children suspected to have liver pathology because it is cheap, quick to perform with no radiation risks. Liver size may be increased or decreased in many pathological conditions and ultrasound is ideal since clinical evaluation by palpation and/or percussion can be unreliable or inaccurate. OBJECTIVE: To our knowledge, no previous study has been done in an exclusively large neonatal population in Sub-Saharan Africa to establish reference values for the liver size. This study aims to determine by USS, the normal range of longitudinal dimensions for the liver in healthy neonates. METHODS: A prospective cross-sectional study of 508 apparently healthy neonates. Routine clinical examination and liver ultrasound scans were performed before discharge or at the immunization clinic. Liver size was taken as the longitudinal dimension in the mid-clavicular line. Normograms with point-wise 95% reference ranges were constructed using a normal approximation. RESULTS: Mean age was 9.67 ± 7.68 days and 51.4% were males. Ultrasound span of the liver ranged from 3.28-8.02 cm with a mean of 5.72 ± 0.88 cm. There was no evidence for sex difference in the liver size, p= 0.338. The liver size correlated most strongly with neonatal weight (r=0.55) and age (r=0.53) which were used in plotting the 95% reference ranges for the neonatal liver normogram. CONCLUSIONS: This study of a large neonatal population has provided the normal range of US liver dimensions for neonates in the study area, using the age and weight in plotting the 95% reference ranges for the liver normogram.

Transcatheter closure of patent ductus arteriosus: report of the first case in Nigeria.

BACKGROUND: Since the first report on device closure of patent ductus arteriosus (PDA) by Porstmann et al in 1967, the procedure has gained wide acceptance and has been used all over the world, including parts of Africa. The advantages when compared to surgical closure include shorter procedure time and hospital stay and no scar being left. This mode of treatment was not available in Nigeria prior to this with patients having to travel abroad to benefit. PATIENT AND METHOD: Cardiac catheterisation laboratory became available in Lagos, Nigeria in 2009 and in October 2010, the laboratory collaborated with Lagos State University College of Medicine (LASUCOM) and Lagos State University Teaching Hospital (LASUTH), to perform a device closure on a 3-year old girl with PDA who had presented to LASUTH with heart failure at the age of 6 months. To the best of our knowledge, this is the first time the procedure has been performed in Nigeria RESULTS: The patient made a successful recovery and is haemodynamically stable, on no medications. CONCLUSION: Device closure of PDA is now safe and available in Nigeria.

Echocardiographic findings among children with sickle cell anaemia at the Lagos University Teaching Hospital.

BACKGROUND: Few studies documenting the echocardiographic findings of patients with sickle cell anaemia have been reported from Africa despite the high prevalence of the disease on the continent. AIMS AND OBJECTIVES: The present study aimed to determine echocardiographic cardiac dimensions and haemodynamic parameters of children with homozygous sickle cell anaemia (SCA), in steady state at the Lagos University Teaching Hospital (LUTH). MATERIALS AND METHODS: Sixty children with SCA and sixty age and sex matched controls with ages ranging from 1-15 years were studied. Their cardiovascular functions were determined by echocardiographic examination. RESULTS: Mean age of SCA patients and controls were 95.41 ± 49.06 months and 95.45 ± 50.9 months respectively (p = 0.97). Mean left atrial dimension (LA), left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), left ventricular posterior wall thickness (LVPW), Interventricular septal thickness (IVS) and left ventricular mass (LVM) in SCA patients were significantly larger than those of controls (p < 0.001 for each parameter). Left ventricular fractional shortening (FS) and ejection fraction (EF) were within acceptable normal limits although significantly lower in SCA patients (p < 0.001). The mean haemoglobin concentration in the subjects (77.23 ± 12.88) was significantly lower than in the controls (121 ± 16.09) (p < 0.001). Each direct echocardiographic parameter (LAD, AO, LVEDD, LVESD, IVS, LVPW and LVM) correlated significantly with age in both groups while left ventricular functional parameters (FS and EF) did not in both groups. Chamber dimensions, LVPW, FS and EF were inversely correlated with haemoglobin concentration in the subjects.

Nephrotic syndrome complicating cyanotic congenital heart disease: a report of two cases.

BACKGROUND: Renal complications are said to be common in cyanotic congenital heart disease (CCHD), but have not been documented frequently in Nigerian children. Nephrotic syndrome (NS) is an uncommon complication of CCHD. OBJECTIVES: To report two cases of NS complicating CCHD who presented within months of each other, in order to draw attention to the problem. METHODS: The details of the clinical presentation, course and outcome of two children with CCHD, presenting with features of NS within months of each other, were reviewed. The patients were fully assessed clinically and were further investigated with chest X-ray, ECG ad echocardiography. RESULTS: A 12-year old girl with Fallot's tetralogy underwent a Blalock-Taussig shunt at the age of 2 years, but subsequently defaulted from follow-up. She reappeared 10 years later with features of NS. Echocardiography revealed impaired myocardial function. Despite initial clinical improvement following three plasma exchanges and Enalapril therapy, she suddenly died on the 15th day of admission. The second patient was a 7-year old boy with tricuspid atresia, diagnosed at the age of 10 months, and similarly defaulted, reappearing six years later with features of NS. Oedema regressed with similar treatment, but his renal function deteriorated. He was stable enough to be discharged after six weeks on admission. CONCLUSION: Proteinuria is likely to be more common in Nigerian children with CCHD than has been previously appreciated. Early intervention in patients with CCHD is desirable in order to prevent development of complications which worsen the prognosis. Patients with CCHD should be screened regularly for proteinuria in order to detect and address renal complications early.

Perceptions of child labour among working children in Ibadan, Nigeria.

BACKGROUND: The adverse effects of child labour on the children's psychological development continue to raise concerns about this public health problem worldwide. Several views have been presented by child health authorities, non-governmental organizations (NGOs) and international agencies. Few studies have focused on the children themselves. This study sought to determine working children's perspective of child labour, its benefits and disadvantages and the working children's perceptions of themselves, and their aspirations for the future. METHODS: A cross-sectional study was carried out among working children in a large market in Ibadan, south-west Nigeria. Questionnaires were administered to all consenting children. RESULTS: A total of 225 children, 132 females and 93 males, participated in the survey. Their age range was 8-17 years. A total of 103 respondents (46%) were currently in school while 117 (52%) were out of school. Five respondents (2%) had never attended school. A total of 104 (46%) thought that children should not work. However, when asked about the benefits of working, 81 working children (36%) felt that work provided a source of income for them, 52 (23%) indicated that it was a way of helping their parents and 39 (17%) thought it was part of their training to be responsible adults. Bad company, ill health and road traffic accidents were the perceived ill effects of child labour. The majority of the children interviewed were aspiring towards artisan trades and very few towards professional or office jobs. A total of 106 (47%) children perceived themselves as less fortunate than their peers. Fifty-five children (24%) thought that child labour was a sign of deprivation. The perception that child labour is a sign of deprivation was more prevalent among child workers whose highest educational attainment was primary school, child workers who had worked for more than 6 months and those whose earnings were small. CONCLUSION: We recommend that school education for children should be a priority even when the harsh economic realities in their families force parents to send them to work outside the home.

Prognostic indices in childhood heart failure.

OBJECTIVES: To evaluate the short term prognosis of childhood heart failure and highlight the factors that affect outcome among cases of heart failure admitted into the paediatric wards, University College Hospital, Ibadan. BACKGROUND: Childhood heart failure remains a major cause of morbidity and mortality in the developing world. The advent of open heart surgery, use of better myocardial preservative techniques, and the introduction of newer, more effective drugs in the treatment of heart failure have greatly improved the outcome of children with heart failure in the developed world. The outlook of such children in the developing world however remains poor. METHODS: One hundred consecutive cases of heart failure admitted into the Paediatric wards of the University College Hospital, Ibadan with a diagnosis of heart failure over a 10-month period were studied prospectively. Diagnosis of heart failure was based on the presence of at least three of the four cardinal signs of heart failure: tachypnoea, tachycardia, tender hepatomegaly and cardiomegaly. All cases were followed up daily till a definite outcome was determined. RESULTS: The predominant underlying causes of heart failure were acute respiratory infections (36%), severe anaemia (28%), and congenital heart disease (25%). There was a case-fatality rate of 24% among the study population. Poor prognostic indices identified were age below one year or above 5 years, presence of underlying acute respiratory infections, rheumatic heart disease and renal disorders. CONCLUSION: Heart failure in Nigerian children though mostly due to preventable causes, are associated with an unacceptably high mortality.

Heart failure complicating tetralogy of Fallot.

BACKGROUND: Heart failure is considered to be an unusual complication of uncorrected tetralogy of Fallot. PATIENTS AND METHOD: Three adolescents with tetralogy of Fallot, presenting in congestive cardiac failure are presented. Two died. Myocardial infarction was found in the only patient that underwent autopsy, and is thought to be an important aetiological factor in the development of the heart failure in the patients. CONCLUSION: The cases presented illustrate the fact that heart failure complicating tetralogy of Fallot may not be as uncommon as was previously thought to be the case, especially in older children. There is a need for early diagnosis and expeditious institution of appropriate management before such complications occur.

Socio-economic determinants of child labour and attitudes to child labour among school children in Ibadan.

This cross sectional study was designed to compare the characteristics of working and non-working school children. Two hundred and thirty one working and 236 non-working children were interviewed. The socio economic factors associated with child labour were trading as mother's occupation, father's educational status, religion, family type (monogamous vs polygamous) and type of residence. Family type (OR = 0.562, 95% C.I. 0.353-0.897, p = 0.016), religion (OR = 0.559, 95% C.I. 0.361-0.867, p = 0.009) and trading as mother's occupation (O.R = 2.49, 95% CI 1.68-3.68, p = 0.000) were sustained on logistic regression analysis. With regard to attitude to child work, 186 (40%) of all respondents thought that children should be allowed to work. The majority of those who held this opinion 150, were child workers. Ten percent of working children had themselves chosen to work without any parental influence to do so. Seventy five respondents had ever repeated a class. Forty nine of these were working children a prevalence of 21% of repeaters compared to 26 non working children, (11%.) p = 0.004. Sixty eight percent of children aspiring to careers in artisan trades were child workers. Road traffic accidents and poor school performance were the commonest adverse effects of child labour indicated by school children. Parents should be educated about the adverse effects of child labour on child development. As poverty is one of the major root causes of child labour, free and compulsory primary education may help to reduce the notion of child work as an option for survival in poor families.

Standard 12 lead and 24 hour Holter electrocardiographic observation in a biracial group of perinatally asphyxiated newborns.

AIM: To compare the cardiovascular responses to perinatal stress between two ethnic groups of newborns. STUDY POPULATION: 23 Nigerians and 14 Dutch perinally asphyxiated newborns together with their respective control of 12 healthy Nigerian and 16 Dutch newborns. METHOD: The study subjects and their controls were evaluated with standard 12-lead and 24-hour Holter electrocardiographic recordings within 36 hours of postnatal life. RESULT: Rhythm, rate, P-wave, P-R interval and QRS duration were normal in study subjects and their respective controls on standard ECG. The prevalence of ST-segment depression in the mid-precordial lead V4 was significantly higher in the asphyxiated Nigerian infants (78%) than in the controls (42%); p < 0.05. Similarly, its prevalence in the Dutch infants (50%) was significanly different from the zero prevalence in the Dutch controls; p < 0.05. Long duration ECG recordings showed a 'fixed heart rate' phenomenon in the asphyxiated infants but not in their controls. CONCLUSION: ST-segment depression may imply myocardial ischaemia in asphyxiated Dutch newborns but such may not be inferred in asphydiated Nigerian newborns. 'Fixed heart rate' phenomenon or loss of sinus arrhythmia appears to be causally related to hypoxaemia which results from perinatal asphyxia.

Childhood heart failure in Ibadan.

One hundred consecutive admissions of children with a diagnosis of congestive cardiac failure to the paediatric department of the University College Hospital, Ibadan were evaluated during a 10-month period. They were aged 8 days to 12 years. They constituted 5.8% of the total paediatric admissions during the study period. The most frequent underlying causes of heart failure were acute lower respiratory tract infections (36%), intrinsic heart disease (31%) and severe anaemia (28%). Other less common causes of heart failure were renal disorders (3%) and septiceamia (2%). Heart failure remains a common problem encountered in emergency paediatric practice in Nigeria, with the majority of cases resulting from preventable causes.

Low plasma bicarbonate predicts poor outcome of cerebral malaria in Nigerian children.

Malaria remains a major cause of morbidity and mortality in many sub Saharan countries and cerebral malaria is widely recognised as one of its most fatal forms. We studied the predictive value of routine biochemical laboratory indices in predicting the outcome of cerebral malaria in 50 Nigerian children ages 9 months to 6 years with cerebral malaria at the University College Hospital, Ibadan, Nigeria. Of the 50 children studied, 43 (68%) made a full recovery, 5 (105) developed neurological sequelae while 11(22%) died. Biochemical derangements observed among the children included azotaemia (29%), elevated plasma creatinine (20%), metabolic acidiosis (22%) and hyponatraemia (16%). Metabolic acidosis and elevated plasma creatinine on admission were significantly associated with a poor outcome (p < 0.05). Hyponatraemia and hypokalaemia were not significantly associated with outcome. On multivariated analysis, metabolic acidosis and elevated plasma creatinine on admission to hospital remained independent predictors of poor outcome after adjusting for other known risk factors. Patients with these findings require prompt referral for adequate treatment in centres equipped to manage such critically ill patients.

The Ibadan conjoined twins: a report of omphalopagus twins and a review of cases reported in Nigeria over 60 years.

An omphalopagus set of female conjoined twins, undiagnosed prenatally, who presented as obstructed labour needing operative delivery is reported. Their anatomic characteristics and clinical features, including overwhelming sepsis in twin II which forced early separation, and those which led to their demise are described. Twelve other cases reported in Nigeria over the past 60 years are reviewed with reference to the aetiology and epidemiology of conjoined twinning and the determinants of successful surgical separation.

Tympanic thermometry in Nigerian children.

Rectal and aural temperatures were recorded at the same time in 378 children aged < or = 60 months and were found to be similar across the various age groups, correlation coefficients (r) ranging from 0.61 to 0.91. The mean differences between rectal and aural temperatures varied between -0.06 and 0.25 degree C. Concordance between the two methods ranged from 88.9% to 98% across the temperature range. Tympanic thermometry is simpler, safer and quicker than rectal thermometry and these findings justify the use of aural thermometry in any busy clinical facility for children.

Significance of a cardiac murmur as the sole clinical sign in the newborn.

A cardiac murmur is a very common finding in the first few days of life. It is traditionally believed that lesions creating left-to-right shunts do not present so early. This study was aimed to define and to classify the causes of a murmur in a newborn with an otherwise normal examination. All echocardiograms performed on newborns aged 1-5 days who were referred for evaluation of a murmur in a 3-year period were reviewed. Newborns with additional clinical signs or antenatal diagnosis of a cardiac disease were excluded. Of 20,323 live births, there were 170 newborns referred for echocardiogram solely because of a murmur. Of these, 147 (86%) were found to have structural heart defects. The most common lesions found were those creating left-to-right shunts (66%). Ventricular septal defect was the most common single lesion (54/147, 37%), followed by patent ductus arteriosus (34 newborns, 23%). The combination of both was found in 10 newborns (7%). Six newborns (4%) had pulmonary valve stenosis and three (2%) aortic valve stenosis. Seven newborns (5%) had unforeseen complex heart disease. For five of them, delayed diagnosis would have resulted in potentially life-threatening conditions. There was no correlation between the category of lesion and the age of presentation. The audible threshold of a murmur correlated with a maximum instantaneous gradient of 25 mm Hg (range 11-46 mm Hg). Thirteen percent of newborns with isolated heart murmur had no identifiable structural heart disease. These data suggest that most asymptomatic newborns presenting with a murmur in the first days of life have structural heart disease. Some of the more serious defects would not have been diagnosed without early echocardiography. A left-to-right shunt, particularly a ventricular septal defect, may cause a murmur even the first day of life and is probably more common that has been acknowledged.

Detection of an obstructive membrane in the ductus arteriosus of a fetus using high frame rate echocardiography.

We examined a fetus at 38 weeks of gestation because of marked disproportion in size of the left and right ventricles. A membrane was detected at the distal end of the ductus arteriosus with significant flow gradient through it. New echocardiographic technologies such as high frame rate imaging and dynamic beam focusing increase spatial and temporal resolution and enhance more precise anatomical diagnosis in the fetus. This ductal membrane might have been related to the transient tachypnea from which the baby suffered after birth.