Prevalence of COVID-19 among healthcare workers in the paediatric department: Estimates from a multicenter cross-sectional survey in Negeri Sembilan

INTRODUCTION

The COVID-19 pandemic has reached a phase where many have been infected at least once. Healthcare workers were not spared from being infected. This study aimed to determine the period prevalence of COVID-19 among the paediatric healthcare workers in Negeri Sembilan as the country transitioned into an endemic phase of the pandemic. Additionally, we investigate potential sociodemographic and occupational characteristics associated with SARS-CoV-2 infection among healthcare workers.

MATERIALS AND METHODS

A cross-sectional study was conducted among the healthcare workers in the paediatric department at three public specialist hospitals in Negeri Sembilan between 15 and 21 April 2022. Data were collected through a self-administered questionnaire.

RESULTS

Out of the 504 eligible healthcare workers, 493 participated in this study (response rate 97.8%). The overall prevalence of COVID-19 (11 March 2020-15 April 2022) among healthcare workers was 50.9%. The majority (80.1%) were infected during the Omicron wave two months before the survey. Household contacts accounted for 35.9% of infection sources. The proportion of non-doctors in the COVID-19-infected group was significantly higher compared to the non-infected group (74.1% vs 64.0%, p=0.016). The COVID-19-infected group had a higher proportion of schoolgoing children (44.6% vs 30.6%, p=0.001) and children who attended pre-school/sent to the babysitter (49.0% vs 24.4%, p<0.001). There were no significant differences between infection rates among the healthcare workers working in the tertiary hospital and the district hospitals. There were also no significant differences in the proportion of COVID-19- infected doctors and nurses when analysed by seniority.

CONCLUSION

Our study provided an estimate on the prevalence of COVID-19 among paediatric healthcare workers in Negeri Sembilan and the factors associated with infection, which captures the extent and magnitude of this pandemic on the state's paediatric department. Most infections resulted from household contact, with a higher proportion of infected healthcare workers having young children.

Leadless left bundle branch pacing: feasibility in an animal model

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): EBR Systems Inc.

Introduction

Epicardial cardiac resynchronization therapy (CRT) is an established treatment for heart failure; left bundle branch (LBB) pacing has been proposed to overcome epicardial CRT limitations. In this study, we report on the first implants of a leadless electrode for endocardial pacing of the LBB in a porcine model.

Methods

The implant of the leadless, left ventricular endocardial pacing system (WiSE-CRT System) was attempted by transeptal approach in two porcines. Fluoroscopic and transoesophageal echocardiographic guidance were used to navigate the Delivery Sheath to the LBB area; the targeted implant site was selected by analysis of the electrograms from the implanting Electrode. At the end of the procedure, the animals were sacrificed and the hearts were isolated and analysed.

Results

In both animals, the Delivery System was successfully navigated to the LV septum. The target sites showed LBB electrograms preceding the far field ventricular electrogram by 15ms. The Electrode was successfully implanted on both animals with pacing threshold &lt;2.0V @ 0.5ms. The implant of the pacing electrode was associated with minimal, multifocal haemorrhage; Purkinje fibers components of the LBB were observed in the on both sides of the site of implantation site. The lesion was 1.7 mm large and 2 mm deep.

Conclusions

This study supports the feasibility of leadless LBB pacing. Anatomical evaluation showed a close relationship between the Electrode and the LBB, with absence of significant damage to the conduction system from the implanted Electrode.

Stridor as a Harbinger of Congenital Cardiovascular Anomaly

BACKGROUND

There is an intimate spatial relationship between the cardiovascular and airway structures. Central airway compression related to congenital cardiovascular anomalies should be considered in neonates, infants, and young children presenting with stridor.

METHODS

From July 31, 1990 to December 31, 2018, 24 pediatric patients, including 18 males and 6 females, aged 1 day to 11.3 years old, presenting with stridor and/or lip cyanosis were enrolled in this study. At presentation, none of the patients had a known history of congenital heart disease. Patients with congenital bronchopulmonary vascular/foregut malformations, congenital pulmonary venolobar syndrome, congenital pulmonary malinosculations, Eisenmenger syndrome, secondary pulmonary hypertension, and idiopathic pulmonary arterial hypertension were excluded from this study. Available profiles of 24 patients were reviewed and the underlying congenital cardiovascular anomalies contributing to the clinical manifestation of stridor were analyzed, including chart recordings, chest radiograms, echocardiograms, computerized tomography, electrocardiograms, esophagograms, cardiac catheterization, magnetic resonance imaging, and bronchography.

RESULTS

Stridor was an early sign of congenital cardiovascular anomalies, including double aortic arch, right aortic arch (RAA) with Kommerell diverticulum, mirror-image right aortic arch with aortic diverticulum, anomalous right innominate artery, left pulmonary artery sling, RAA with tetralogy of Fallot and persistent fifth aortic arch, a vertical patent ductus arteriosus from a transverse left aortic arch, and absent pulmonary valve syndrome. Notably, chest radiography provided the first clue of RAA in 18 of the 24 patients.

CONCLUSIONS

Stridor can be a harbinger of congenital cardiovascular anomalies causing central airway compression in pediatric patients.

Predictors and a novel risk score of statin non-adherence after hospitalisation for an acute coronary syndrome

Background

Statin non-adherence after acute coronary syndrome (ACS) hospitalisation is associated with adverse prognosis. Identifying its risk factors can help to develop strategies and target high risk groups to improve outcomes. We evaluated the predictors and devised a risk score for statin non-adherence following ACS.

Methods

Consecutive ACS hospitalisations enrolled in the ANZACS-QI registry during December 2013 to October 2017 were linked to the National Pharmaceutical database for statin dispensing records. The primary endpoint was mean statin possession ratio (MPR) of &lt;0.8 at 6–12 months after discharge. Multivariable Poisson regression was performed to identify predictors and formulate a risk model for statin non-adherence.

Results

Primary endpoint occurred in 4736/19942 (24%) of ACS patients studied. Patients taking statin on admission with LDL-cholesterol&lt;2mmol/L had the lowest risk and were chosen as the reference group. Adjusted relative risks (RR) and 95% confidence intervals (95% CI) were highest in patients with prior cardiovascular disease (CVD) but not on statins 3.79 (3.42–4.20), followed but no prior CVD and not on statins 2.25 (2.04–2.48). RRs (95% CI) for patients on statin with LDL2.0–2.9 and LDL &gt;3.0mmol/L were 1.33 (1.17–1.50) and 1.96 (1.72–2.24) respectively. Other independent predictors were age&lt;45 years, Māori, Pacific and no revascularisation. Together, a risk score out of 25 for statin non adherence was created.

Conclusion

Statin non-adherence remains prevalent after ACS, with history of CVD, statin use and LDL levels being key predictors. A risk model was developed to help identify at risk patients that may benefit the most from delivery of adherence improving interventions and warrants external validation.

Funding Acknowledgement

Type of funding sources: None.

Systemic hypertension followed by insidious stroke in a 12-year-old boy with childhood neurofibromatosis type 1 presenting with renal and cerebral artery vasculopathy

Lee ML, Chang TM, Yang RC, Yang AD, Chen M. Systemic hypertension followed by insidious stroke in a 12-year-old boy with childhood neurofibromatosis type 1 presenting with renal and cerebral artery vasculopathy. Turk J Pediatr 2019; 61: 629-634. Neurofibromatosis type 1 (NF1)-associated vasculopathy is usually diagnosed decades after the clinical diagnosis of NF1. Childhood NF1-associated renal artery vasculopathy or moyamoya-like brain vasculopathy could be clinically silent for a long time. We report a 12-year-old boy who had systemic hypertension found incidentally at a routine check-up. Physical examination showed caféau- lait spots and strong radial pulses. Abdominal computerized tomography angiography showed severe right ostial renal artery stenosis. Genomic study showed a heterozygous mutation c.5902C > T (p.R1968*) and two heterozygous single nucleotide polymorphisms (NCBI: SNP rs18011052 and rs2905876) of NF1 gene. After endovascular revascularization for renovascular hypertension caused by renal artery stenosis, including percutaneous transluminal renal angioplasty and stent implantation, blood pressure dropped effectively from 205/143 mmHg to 130/90 mmHg. Supine renin level dropped from 87.2 pg/ mL to 47.9 pg/mL. Unfortunately, right hemiplegia, transient visual loss with blind spots (scotomas), and clumsiness of extremities emerged insidiously 3.5 months later. Brain magnetic resonance imaging and magnetic resonance angiography showed ischemic infarction involving the watershed area of the anterior and middle cerebral arteries, indicating presence of moyamoya-like brain vasculopathy. A dilemma is that a significant decrease of blood pressure after endovascular revascularization for renal artery stenosis may have potentially unmask the moyamoya-like brain vasculopathy in this patient. Vasculopathy could be heralding childhood NF1 in the young patients without full-fledged clinical features. Endovascular revascularization for renal artery stenosis could be a double-edge sword in childhood NF1 presenting with concomitant renal and cerebral artery vasculopathy.

Health-related quality of life in paediatric spina bifida

INTRODUCTION

The average incidence of spina bifida (SB) in Malaysia is 0.43 among 1,000 live births. The burden of the disease and its impact on the overall development and health though tremendously improved, remains significant. Therefore, current patient management strategies must include quality of life (QOL) measures.

METHODS

This was a prospective, cross-sectional study on spina bifida children aged 5-20 years, attending the paediatric spina bifida clinics of Universiti Kebangsaan Malaysia Medical Centre Kuala Lumpur and Hospital Tuanku Jaanku Seremban. Scores were obtained using the validated disease specific Parkin QOL questionnaire. Univariate and multivariate analysis were used to investigate factors that were determinants for these outcomes. Results were expressed as beta coefficient and 95% confidence intervals (95%CI).

RESULTS

A total of 54 children and adolescents aged between 5-20 years completed the questionnaires. Presence of neurogenic bowel (p=0.003), neurogenic bladder (p=0.041), shunt (p=0.044), non-ambulators (p=0.007) and being the only child in the family (p=0.037) were associated with lower QOL scores. Multivariate analysis showed presence of neurogenic bowel (β=0.375, 95%CI: 0.00, 0.15) and being the only child in the family (β=0.250, 95%CI: 0.04, 0.17) explained 22.1% of the variance in the QOL mean percentage scores.

CONCLUSION

Being a single child in the family was the only socio-demographic variable associated with lower QOL scores. Although several clinical factors appeared to contribute significantly to QOL in spina bifida children, the presence of neurogenic bowel had the greatest impact.

Influence of apical position on the left ventricular outflow tract obstruction in congenitally corrected transposition

BACKGROUND

The right ventricle has a proclivity to wrap around the left ventricle outflow tract (LVOT) in congenitally corrected transposition (CCT) patients with apicocaval ipsilaterality, which may influence the outcome of the double switch operation (DSO). The goal of this study was to determine if the LVOT is compressed by the right ventricle in this setting.

METHODS

A total of 103 patients with CCT were divided into four groups according to ventricular looping and apical position, including Group A (D-loop and levocardia), Group B (L-loop and dextrocardia), Group C (D-loop and dextrocardia), and Group D (L-loop and levocardia). Computed tomography was used to define left-right laterality and ventro-dorsal relationship of the LVOT.

RESULTS

Apicocaval ipsilaterality was found in 57 patients (Group A, n=25; Group B, n=32), in whom the right ventricle was found to wrap around the LVOT. Among them, 49 (86%) had LVOT obstruction. In 46 patients without apicocaval ipsilaterality (Group C, n=10; Group D, n=36), 31 had LVOT obstruction (67.4%). LVOT obstruction was more prone to occur in patients with apicocaval ipsilaterality compared with those without (p=0.025), and was more significant in the situs solitus (p=0.058) than in situs inversus (p=0.547).

CONCLUSIONS

LVOT obstruction was prone to occur in CCT patients with situs solitus and apicocaval ipsilaterality (Group B). The ventricular outflow patency was influenced by apical position, which should be considered to avoid a posterior ventricular outflow tract from compression after DSO.

The Concept of the Arch Window in the Spiral Switch of the Great Arteries

When the arterial switch operation includes the Lecompte maneuver, the arterial trunks are reconnected in parallel, rather than the spiral fashion observed in the normal heart. Thus, although the ventriculo-arterial connections are hemodynamically corrected, the anatomic arrangement cannot be considered normal. We hypothesized that, if feasible, it would be advantageous to restore a spiral configuration for the arterial trunks. In 58 patients, we reconstructed the arterial trunks such that, postoperatively, the pulmonary channel spirals round the aorta, passing to either the right or the left, and branches posteriorly. We compared the outcomes with those in 95 patients undergoing a standard non-spiraling operation over the same period. Average follow-up was 8.2 ± 4.5 years. The estimated 10-year survival was similar in the cohorts, at 94.7 % for those with spiraling trunks, as compared to 90.4 % for those with parallel outflow tracts. Reoperation-free survival at 10 years was not significantly different (87.6 vs. 90.5 %). Supravalvar pulmonary stenosis, aortic neo-coarctation, or left bronchial stenosis, however, was encountered in one-eighth of those undergoing a standard operation. None of these complications occurred in those patients who, postoperatively, had spiraling outflow tracts (P = 0.002). Reconstruction of spiraling trunks after the arterial switch has, thus far, avoided the complications of supravalvar pulmonary stenosis, neo-aortic kinking, or bronchial stenosis. The spiraling arrangement prevents compression of the pulmonary vessels and bronchial tree by the aorta, since it provides a wide window in the new aortic arch.

A randomized, double-blind, placebo-controlled pilot study of IV immune globulins in combination with IV methylprednisolone in the treatment of relapses in patients with MS

Background: Some patients with multiple sclerosis (MS) do not show a clear improvement of acute relapses after treatment with intravenous methylprednisolone (IVMP). We compared the efficacy of the combination of intravenous immunoglobulins (IVIg) and IVMP with the standard treatment of IVMP alone in promoting recovery from moderate to severe acute relapses in MS. Methods: Patients with clinically definite MS having a relapse with at least a one point increase in Kurtzke’s expanded disability status scale (EDSS) in comparison to the preattack EDSS were randomized to IVMP-IVIg or IVMP-placebo treatment. The primary outcome criterion was the EDSS grade at four weeks. A preplanned interim analysis was performed after inclusion of 19 consecutive MS patients to evaluate the sample size necessary for a larger trial. Findings: Both groups had improved one point on the EDSS four weeks after start of treatment (P =0.81) and one of the stopping rules of the interim analysis was fulfilled. There were also no differences in secondary outcomes: EDSS at eight and 12 weeks, time to improve]-1 EDSS points, difference in Scripps score and ambulation index. Five patients in the IVMP-IVIg group and two in the IVMP group had a new relapse in the six month follow-up. Interpretation: O ur study could not show superiority of IVMP-IVIg in the treatment of moderate to severe acute relapses in MS.

Late onset of large benign ductus arteriosus aneurysm presented with increased nuchal translucency and cystic hygroma at first trimester Down syndrome screening

OBJECTIVE

Fetal ductus arteriosus aneurysm (DAA) is a rare but potentially risky congenital heart disease. It is often not diagnosed until the third trimester because of its asymptomatic nature and late onset. In rare occasions, DAA may result in serious complications; therefore, prenatal diagnosis is helpful.

CASE REPORT

Herein, we report the case of a foetus with cystic hygroma and increased nuchal translucency in the first trimester (but regressed at 20-week anomalous scan). Karyotyping indicated a 46 XY genotype. A large vascular mass was noted at the apex of the left lung by Doppler ultrasound at 38 weeks of gestation, with a diameter of 12.5 mm. After birth, echocardiography showed a patent ductus arteriosus with aneurysmal dilatation (17 mm as the largest diameter); thus, DAA was impressed. Chest computed tomography and three-dimensional angiography confirmed the large aneurysmal dilatation of the ductus arteriosus with a closed end at the pulmonary arterial side.

CONCLUSION

The male infant survived, but presented mild respiratory distress at birth. He was discharged at 24 days of age. At that time, DAA had regressed partially (diameter of 8.5 mm and much less blood flow), and it fully regressed at 40 days of age.

Upregulation of Haploinsufficient Gene Expression in the Brain by Targeting a Long Non-coding RNA Improves Seizure Phenotype in a Model of Dravet Syndrome

Dravet syndrome is a devastating genetic brain disorder caused by heterozygous loss-of-function mutation in the voltage-gated sodium channel gene SCN1A. There are currently no treatments, but the upregulation of SCN1A healthy allele represents an appealing therapeutic strategy. In this study we identified a novel, evolutionary conserved mechanism controlling the expression of SCN1A that is mediated by an antisense non-coding RNA (SCN1ANAT). Using oligonucleotide-based compounds (AntagoNATs) targeting SCN1ANAT we were able to induce specific upregulation of SCN1A both in vitro and in vivo, in the brain of Dravet knock-in mouse model and a non-human primate. AntagoNAT-mediated upregulation of Scn1a in postnatal Dravet mice led to significant improvements in seizure phenotype and excitability of hippocampal interneurons. These results further elucidate the pathophysiology of Dravet syndrome and outline a possible new approach for the treatment of this and other genetic disorders with similar etiology.

Platypnea-Orthodeoxia Syndrome Two Decades after Definitive Surgical Repair of Pulmonary Atresia with Intact Ventricular Septum

A 20-year-old female had undergone definitive surgical repair for pulmonary atresia with intact ventricular septum soon after birth. She was referred to our institution with the chief complaint of clubbing fingers. A thorough examination revealed platypnea-orthodeoxia syndrome due to an interatrial right-to-left shunt through a secundum atrial septal defect. Percutaneous closure with an Amplatzer Septal Occluder resulted in resolution of the syndrome.

Transjugular Balloon Pulmonary Valvuloplasty Through a Bidirectional Glenn Shunt for Dysplastic Pulmonary Valve Stenosis in an 8.7-Year-Old Boy with Inaccessible Femoral Veins

An 8.7-year-old boy was affected by exertional dyspnea with cyanosis of the lip at 6 years old. Oxygen saturation (SpO2) was 66%. A bidirectional Glenn shunt (BGS) was constructed to successfully elevate SpO2 to 88%. Unfortunately, he again experienced exertional dyspnea with flagrant cyanosis of the lip at 8.5 years old. SpO2 decreased to 65%. Echocardiography revealed a dysplastic pulmonary valve with severe stenosis. Considering the potential growth of the right ventricle and the branch pulmonary arteries, transjugular balloon pulmonary valvuloplasty (BPV) through a BGS was performed as a palliative treatment for cyanosis in this boy because of inaccessible femoral veins. After gradational BPV, the opening of the pulmonary valve was dilated from 2.59 mm to 6.65 mm, the pressure gradient decreased from 60 mmHg to 25 mmHg, and the SpO2 increased to 85%. He became physically active and was free of exertional dyspnea at the 12-month follow-up. BGS is irrefutably an alternative vascular access through which transjugular BPV could be performed to ameliorate cyanosis due to dysplastic pulmonary valve stenosis in patients with inaccessible femoral vessels.

Abstract P5-06-02: Proliferative breast disease identified by nipple aspirate fluid cytopathology has the laterality and asymmetry characteristics of breast cancer, supporting the thesis it is a cancer precursor

Introduction. Within the basket of conditions known as Benign Breast Disease, Proliferative Breast Disease (PBD) is a finding at biopsy or aspiration of either benign hyperplasia or atypical hyperplasia (ADH). PBD is known to confer increased risk of future breast cancer [Hartmann, NEJM 2015;372:78-89]. However, there is some controversy as to whether these lesions are precursors to breast cancer (BCa), in which their synchronicity and asymmetry should match BCa, or alternatively, if they are biomarkers of risk, in which future cancers would not necessarily be linked in time and space to earlier PBD lesions. The Left-dominant asymmetry was first described over half a century ago, but its molecular origins in embryonic development have only recently been characterized.[Wilting. J.Current Medic Chem 2011; 18:5519-27]. This study was conducted to explore if a similar pattern of asymmetry and unilateral v. bilateral incidence might exist in PBD. This could help to resolve the question of whether PBD is a precursor to BCa or merely a biomarker.

Methods. We examined Nipple Aspirate Fluid (NAF) for evidence of proliferative cytopathology, defined as a finding of either hyperplasia or ADH. NAF was collected using either one of two models of aspirator devices (ForeCYTE™ or HALO™). NAF is aspirated, dispersed on a flower filter, sprayed with fixative and stained with the Pap stain prior to cytologic characterization. Filters mounted whole on glass are placed directly under the microscope. This method allows for a diagnostically interpretable specimen in NAF-droplets as little as 0.007 µL, 1000-fold smaller than the unassisted visual detection limit. A central lab evaluated all specimens.

Results. Between 1/2012 and 6/2013, 1154 women without prior BCa (Age range 18-85; median 48, mean 47.9) consented to submit bilateral NAF specimens; 99.7% of breasts yielded NAF adequate for analysis, evidenced by presence of a duct-selective protein assay on the filter. PBD was found in 149 women, of whom 24 bilateral. The distribution is shown in the table below.

Distribution of benign and atypical hyperplasia among 149 women with PBD Left-onlyRight onlyBilateralCCR 4594218CCR 51684CCR4 (L) and CCR5 (R)--2Total Women755024King Classification: CCR4 = Benign hyperplasia; CCR5 - Atypical Hyperplasia (ADH)

Benign hyperplasia was found in 121 women: 10.5% of those tested. It was bilateral in 13% of cases and left-sided only in 57%. ADH was found in 30 women or 2.6% of those tested. When present, ADH was bilateral in 13% (4/30), L-sided only 53% (16/30) and R-sided only 33% (10/30) of the time. Total PBD identified by NAF cytopathology occurred in 13% (149/1154) of this population, was bilateral in 16.1% (24/149), L-only in 50.3% (75/149)and R-only in 33.5% 50/149). The excess left-sided occurrence of 17% was significant (p=0.048 by chi-square).

Conclusion. This is the first report describing laterality and symmetry of PBD as made by non-invasive NAF collection and demonstrates that the pattern observed is similar to what is seen with invasive breast cancer and in situ lesions, supporting the hypothesis that PBD are precursor lesions to breast cancer.

Citation Format: Kylstra JW, Kalnoski MH, Vo T, Lee ML, Chen S-C, Quay SC. Proliferative breast disease identified by nipple aspirate fluid cytopathology has the laterality and asymmetry characteristics of breast cancer, supporting the thesis it is a cancer precursor. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-06-02.

Angioplasty for recurrent renal artery stenosis in flare-up of Hashimoto's thyroiditis

Takayasu arteritis is the most common disease seen in children presenting with renovascular hypertension (RVH) in Asia, and can manifest anatomically as renal artery stenosis (RAS). We report the case of a 16-year-old girl presenting with RVH due to recurrent and novel RAS in Hashimoto's thyroiditis (HT) flare-up. After treatment with thyroxin and percutaneous transluminal renal angioplasty (PTRA), she was free of hypothyroidism and systemic hypertension. RVH due to recurrent and novel RAS in HT flare-up has not previously been reported in the English-language literature. PTRA is the procedure of choice, providing there is no renal artery dissection or aneurysm.

Wheezing as a sign of cor triatriatum sinister culminating in multiple organ failure

Cardiac asthma or cardiac wheezing (CW) refers to a syndrome of dyspnea and wheezing that mimicks asthma clinically. Reported herein is the case of a 2-month-old boy who presented with refractory wheezing as a sign of cor triatriatum sinister (CTS) that culminated in overwhelming multiple organ failure in a short time. On the day of admission, oxygen saturation (SpO2 ) was <80%. Heart rate was 198 beats/min and respiratory rate 58 breaths/min. Chest radiogram showed pulmonary edema. Electrocardiogram showed right atrial enlargement and right ventricular hypertrophy. N-terminal pro-brain natriuretic peptide (NTproBNP) was very high at >20,000 pg/mL. Two-dimensional echocardiography with Doppler showed CTS, which was complicated with severe pulmonary arterial hypertension due to flagrant pulmonary venous obstruction. Cardiac surgery was undertaken, after which pulmonary edema subsided, SpO2 increased to ≥96%, and NTproBNP dropped to normal. He was discharged 11 days later, and was free of cardiac, pulmonary, renal, and neurological sequelae at 24 month follow up.

Spatially resolved In and As distributions in InGaAs/GaP and InGaAs/GaAs quantum dot systems

InGaAs quantum dots (QDs) on GaP are promising for monolithic integration of optoelectronics with Si technology. To understand and improve the optical properties of InGaAs/GaP QD systems, detailed measurements of the QD atomic structure as well as the spatial distributions of each element at high resolution are crucial. This is because the QD band structure, band alignment, and optical properties are determined by the atomic structure and elemental composition. Here, we directly measure the inhomogeneous distributions of In and As in InGaAs QDs grown on GaAs and GaP substrates at the nanoscale using energy dispersive x-ray spectral mapping in a scanning transmission electron microscope. We find that the In distribution is broader on GaP than on GaAs, and as a result, the QDs appear to be In-poor using a GaP matrix. Our findings challenge some of the assumptions made for the concentrations and distributions of In within InGaAs/GaAs or InGaAs/GaP QD systems and provide detailed structural and elemental information to modify the current band structure understanding. In particular, the findings of In deficiency and inhomogeneous distribution in InGaAs/GaP QD systems help to explain photoluminescence spectral differences between InGaAs/GaAs and InGaAs/GaP QD systems.

Cutting balloon angioplasty for in-stent restenosis of the aortic coarctation in a young boy presenting with systemic hypertension of the upper extremities

An 8.25-year-old boy was incidentally found to have systemic hypertension of the upper extremities. Blood pressures of the upper extremities were 142-150/86-98 mmHg, and those of the lower extremities 110-116/60-66 mmHg. Doppler echocardiography showed in-stent restenosis of the aortic coarctation. Traditional high-pressure balloon angioplasty failed to dilate this inveterate in-stent restenosis. Instead, a cutting balloon angioplasty was performed. The lumen was dilated from 4.80 mm to 7.89 mm. The pressure gradient dropped from 32 mmHg to 9 mmHg. Blood pressures of the upper extremities were 112-116/76-78 mmHg, and those of the lower extremities 100-104/70-72 mmHg. This paper highlights that a cutting balloon angioplasty can serve as a juste milieu to relieve in-stent restenosis of the aortic coarctation when traditional high-pressure balloon angioplasty is debatable.

InGaN working electrodes with assisted bias generated from GaAs solar cells for efficient water splitting

Hydrogen generation through water splitting by n-InGaN working electrodes with bias generated from GaAs solar cell was studied. Instead of using an external bias provided by power supply, a GaAs-based solar cell was used as the driving force to increase the rate of hydrogen production. The water-splitting system was tuned using different approaches to set the operating points to the maximum power point of the GaAs solar cell. The approaches included changing the electrolytes, varying the light intensity, and introducing the immersed ITO ohmic contacts on the working electrodes. As a result, the hybrid system comprising both InGaN-based working electrodes and GaAs solar cells operating under concentrated illumination could possibly facilitate efficient water splitting.

Two-stage endovascular balloon angioplasty and stent implantation for supravalvular pulmonary stenosis in a 33-month-old boy incurring congestive heart failure following arterial switch operation

We report a 33-month-old boy, who had undergone arterial switch operation (ASO) for simple transposition of the great arteries (TGA) since birth, presenting with exercise intolerance with dyspnoea, tachypnoea, tachycardia, cardiomegaly and hepatomegaly. Doppler echocardiography showed severe tricuspid regurgitation and dilatation of the right atrium. At 28 months, cardiac catheterization tracked down the culprit to be right ventricular outflow tract obstruction (RVOTO) manifested at the mid-portion of the main pulmonary artery (MPA) as supravalvular pulmonary stenosis (SVPS) and measuring 2.98 mm in diameter. There was a pressure gradient of 76 mmHg between the right ventricle and the distal portion of the MPA. The lumen was initially dilated to 6.79 mm by balloon angioplasty (BA), after which the pressure gradient dropped to 51 mmHg. However, cardiomegaly and hepatomegaly lingered for 5 months. Stent implantation (SI) was performed at 33 months, after which the lumen was dilated to 9.99 mm and the pressure gradient dropped to 20 mmHg. Liver span decreased from 10 cm to 6 cm.There was a recrudescence of physical activity. Echocardiography showed regression of tricuspid regurgitation and dilatation of the right atrium at the 12-month follow-up.

Mn-doped GaN as photoelectrodes for the photoelectrolysis of water under visible light

Hydrogen generation through direct photoelectrolysis of water was studied using photoelectrochemical (PEC) cells made of Mn-doped GaN photoelectrodes. In addition to its absorption of the ultraviolet spectrum, Mn-doped GaN photoelectrodes could absorb photons in the visible spectrum. The photocurrents measured from PEC cells made of Mn-doped GaN were at least one order higher than those measured from PEC cells made of undoped GaN-working electrodes. Under the visible light illumination and a bias voltage below 1.2 V, the Mn-doped GaN photoelectrodes could drive the water splitting reaction for hydrogen generation. However, hydrogen generation could not be achieved under the same condition wherein undoped GaN photoelectrodes were used. According to the results of the spectral responses and transmission spectra obtained from the experimental photoelectrodes, the enhanced photocurrent in the Mn-doped GaN photoelectrodes, compared with the undoped GaN photoelectrodes, was attributable to the Mn-related intermediate band within the band gap of GaN that resulted in further photon absorption.

Immersed finger-type indium tin oxide ohmic contacts on p-GaN photoelectrodes for photoelectrochemical hydrogen generation

In this study, we demonstrated photoelectrochemical (PEC) hydrogen generation using p-GaN photoelectrodes associated with immersed finger-type indium tin oxide (IF-ITO) ohmic contacts. The IF-ITO/p-GaN photoelectrode scheme exhibits higher photocurrent and gas generation rate compared with p-GaN photoelectrodes without IF-ITO ohmic contacts. In addition, the critical external bias for detectable hydrogen generation can be effectively reduced by the use of IF-ITO ohmic contacts. This finding can be attributed to the greatly uniform distribution of the IF-ITO/p-GaN photoelectrode applied fields over the whole working area. As a result, the collection efficiency of photo-generated holes by electrode contacts is higher than that of p-GaN photoelectrodes without IF-ITO contacts. Microscopy revealed a tiny change on the p-GaN surfaces before and after hydrogen generation. In contrast, photoelectrodes composed of n-GaN have a short lifetime due to n-GaN corrosion during hydrogen generation. Findings of this study indicate that the ITO finger contacts on p-GaN layer is a potential candidate as photoelectrodes for PEC hydrogen generation.

Aggressive versus Low Dose Inhibition of the Renin-Angiotensin System for the Treatment of Microalbuminuria in Type 2 Diabetic Patients: A Pilot Study

Objective. This study compares low dose versus aggressive inhibition of the renin angiotensin system (RAS) to treat microalbuminuria (MA). Methods. Patients with MA after a run-in period to control BP to <130/80 mm Hg with 10 mg benazepril plus other drugs and HbA1c levels to <8.0% were randomized to either continue 10 mg benazepril (N = 12) or to take maximal doses of benazepril plus losartan in monthly stepwise increases to achieve normoalbuminuria (N = 11). Because MA is associated with CVD and inflammation, carotid intima medial thickness (CIMT) and endothelial function by peripheral arterial tonometry (PAT) as surrogate indices of atherosclerosis and highly sensitive C-reactive protein (hs-CRP) to assess inflammation were measured every six months. Results. BP, HbA1c levels, albumin : creatinine ratios, CIMT, PAT, and hs-CRP did not differ over a mean of 12 months between the two groups. Conclusions. Aggressive inhibition of the RAS is unnecessary to treat MA.

Hydrogen gas generation using n-GaN photoelectrodes with immersed Indium Tin Oxide ohmic contacts

An n-GaN photoelectrochemical (PEC) cell with immersed finger-type indium tin oxide (ITO) ohmic contacts was demonstrated in the present study to enhance the hydrogen generation rate. The finger-type ITO ohmic contacts were covered with SiO₂ layers to prevent the PEC cell from generating leakage current. Using a 1M NaCl electrolyte and external biases, the typical photocurrent density and gas generation rate of the n-GaN working electrodes with ITO finger contacts were found to be higher than those with Cr/Au finger contacts. The enhancement in photocurrent density or gas generation rate can be attributed to the transparent ITO contacts which allowed the introduction of relatively more photons into the GaN layer. No significant corrosion was observed in the ITO layer after the PEC process compared with the Cr/Au finger contacts which were significantly peeled from the GaN layer. These results indicate that the use of n-GaN working electrodes with finger-type ITO ohmic contacts is a promising approach for PEC cells.

Restoration of Transposed Great Arteries to Nature

Surgical correction of transposition of the great arteries was proposed by many in the past half-century and was claimed as the anatomical correction, but the treatment of choice was ever changing. The current technique usually includes the Lecompte maneuver to bring the pulmonary bifurcation in front of the aorta. Although the ventricular–arterial connection is corrected, it is not “normal.” This review describes an innovative technique to reconstruct the great arteries in spiral fashion, which is the natural relationship of the aorta and pulmonary artery. The surgical principles of nature and even distribution using autologous tissues are emphasized. The structural and functional studies of the spiral great arteries in the last 2 decades are also presented.

Clinical features, acute complications, and outcome of Salmonella meningitis in children under one year of age in Taiwan

Background

Salmonella meningitis remains a threat to children below two years of age in both developing and developed countries. However, information on such infections has not been well characterized. We analyzed data related to twelve years of experience in order to clarify the comprehensive features of Salmonella meningitis in our patients, including admission characteristics, acute complications, and long-term outcome.

Methods

The records of patients with spontaneous Salmonella meningitis from 1982 to 1994 were retrospectively reviewed. The long-term outcome was prospectively determined for survivors at school age by the developmental milestones reported by their parents and detailed neurological evaluation along with intelligence, hearing, visual, speech and language assessments.

Results

Of the twenty-four patients, seizures were noted in fifteen (63%) before admission and thirteen (54%) during hospitalization. Acute complications mainly included hydrocephalus (50%), subdural collection (42%), cerebral infarction (33%), ventriculitis (25%), empyema (13%), intracranial abscess (8%), and cranial nerve palsy (8%). Three patients (13%) died during the acute phase of Salmonella meningitis. The twenty-one survivors, on whom we followed up at school age, have sequelae consisting of language disorder (52%), motor disability (48%), intelligence quotient < 80 (43%), epilepsy (33%), sensorineural hearing loss (17%), visual deficits (10%), abducens nerve palsy (5%), microcephaly (5%), and hydrocephalus (5%). Overall, good outcome was noted in six (28.6%) of twenty-one survivors, mild sequelae in three (14.2%), moderate in six (28.6%), and severe in six (28.6%).

Conclusion

Salmonella meningitis in neonates and infants had a wide spectrum of morbidity and acute complications, leading to a complicated hospital course and subsequently a high prevalence of permanent adverse outcome. Thus, early recognition of acute complications of Salmonella meningitis and a follow-up plan for early developmental assessment of survivors are vital.

High prevalence of normal tests assessing hypercortisolism in subjects with mild and episodic Cushing's syndrome suggests that the paradigm for diagnosis and exclusion of Cushing's syndrome requires multiple testing

Many Endocrinologists believe that a single determination of eucortisolism or a single demonstration of appropriate suppression to dexamethasone excluded Cushing's syndrome, except in what was previously thought to be the rare patient with episodic or periodic Cushing's syndrome. We hypothesize that episodic Cushing's syndrome is relatively common and a single test assessing hypercortisolism may not be sufficient to accurately rule out or diagnose Cushing's syndrome and retrospectively examined the number of normal and abnormal tests assessing hypercortisolism performed on multiple occasions in 66 patients found to have mild and/or episodic Cushing's syndrome compared to a similar group of 54 patients evaluated for, but determined not to have Cushing's syndrome. We found that 65 of the 66 patients with Cushing's syndrome had at least one normal test of cortisol status and most patients had several normal tests. The probability of having Cushing's syndrome when one test was negative was 92% for 23:00 h salivary cortisol, 88% for 24-h UFC, 86% for 24-h 17OHS, and 54% for nighttime plasma cortisol. These results demonstrated that episodic hypercortisolism is highly prevalent in subjects with mild Cushing's syndrome and no single test was effective in conclusively diagnosing or excluding the condition. Rather, the paradigm for the diagnosis should be a careful history and physical examination and in those patients in whom mild Cushing's syndrome/disease is strongly suspected, multiple tests assessing hypercortisolism should be performed on subsequent occasions, especially when the patient is experiencing signs and symptoms of short-term hypercortisolism.

Academy of medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy

The Academy of Medicine, Singapore (AMS) and the Ministry of Health (MOH) publish clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the AMS-MOH clinical practice guidelines on the Management of Food Allergy, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Academy of Medicine website: http://www.ams.edu.sg/guidelines.asp#foodallergy. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Mirror-image type D interrupted aortic arch: a novel cardiac phenotype providing some perspective in the del22q11.2 syndrome

A 1-day-old baby boy was referred from a local obstetric clinic due to feeble crying, tachypnea, and tachycardia. Two-dimensional echocardiography with Doppler and multidetector computer tomography showed mirror-image type D interrupted aortic arch, conotruncal ventricular septal defect, and patent ductus arteriosus. Emergency cardiac surgery by a biventricular Norwood procedure was performed to relieve his symptom and sign of congestive heart failure successfully. Thymus could not be seen by surgical exploration of the superior mediastinum. Serum C-terminal parathyroid hormone was decreased to less than the normal lower limit. Cytogenetic analysis and fluorescence in situ hybridization study of blood revealed a deletion in chromosome 22q11.2. To the best of our knowledge, mirror-image type D interrupted aortic arch has never been reported in patients with the del22q11.2 syndrome in the English literature. This unusual aortic arch anomaly may provide us a new perspective in the spectrum of cardiovascular malformations in the del22q11.2 syndrome and advocate 22q11.2 deletion as one of the genetic causes of some rare aortic arch anomalies and their correspondent mirror-images.

Gene expression profiling following short-term and long-term morphine exposure in mice uncovers genes involved in food intake

Addictive drugs including opioids activate signal transduction pathways that regulate gene expression in the brain. However, changes in CNS gene expression following morphine exposure are poorly understood. We determined changes in gene expression following short- and long-term morphine treatment in the hypothalamus and pituitary using genome-wide DNA microarray analysis and confirmed those alterations in gene expression by real-time reverse transcriptase polymerase chain reaction (RT-PCR) analysis. In the hypothalamus, short-term morphine administration up-regulated (at least twofold) 39 genes and down-regulated six genes. Long-term morphine treatment up-regulated 35 genes and down-regulated 51 genes. In the pituitary, short-term morphine administration up-regulated 110 genes and down-regulated 29 genes. Long-term morphine treatment up-regulated 85 genes and down-regulated 37 pituitary genes. Microarray analysis uncovered several genes involved in food intake (neuropeptide Y, agouti-related protein, and cocaine and amphetamine-regulated transcript) whose expression was strongly altered by morphine exposure in either the hypothalamus or pituitary. Subsequent RT-PCR analysis confirmed similar regulation in expression of these genes in the hypothalamus and pituitary. Finally, we found functional correlation between morphine-induced alterations in food intake and regulation of genes involved in this process. Changes in genes related to food intake may uncover new pathways related to some of the physiological effects of opioids.

Congenital stridor and wheezing as harbingers of the del22q11.2 syndrome presenting cardiovascular malformations of right aortic arch, aberrant left subclavian artery, Kommerell's diverticulum, and left ligamentum arteriosum

A complete vascular ring composed of right aortic arch, aberrant left subclavian artery with Kommerell's diverticulum, and left ligamentum arteriosum was diagnosed by barium esophagography, echocardiography, angiography, and multidetector computed tomography of chest in an 18-day-old male neonate who presented with remarkable inspiratory stridor, expiratory wheezing, postprandial vomiting, and dysphagia since birth, and survived surgical division of the left ligamentum arteriosum, resection of the Kommerell's diverticulum, and reimplanation of the left subclavian artery to the left common carotid artery. Cytogenetic analysis and fluorescence in situ hybridization study of his blood revealed chromosome 22q11.2 deletion, with a karyotype of 46,XY.ish del(22)(q11.2 q11.2). A constellation of right aortic arch, aberrant left subclavian artery with Kommerell's diverticulum, and left ligamentum arteriosum in neonates may cause refractory stridor, wheezing, vomiting, and dysphagia, which can serve as harbingers of the del22q11.2 syndrome.

Outcomes in neonates with pulmonary atresia and intact ventricular septum underwent pulmonary valvulotomy and valvuloplasty using a flexible 2-French radiofrequency catheter

PURPOSE

Outcomes in 6 neonates with pulmonary atresia and intact ventricular septum (PAIVS) undergoing radiofrequency pulmonary valvulotomy and valvuloplasty (RPVV) were reported to identify the factors favorable for RPVV as the treatment of choice.

MATERIALS AND METHODS

From May 2000 to January 2008, 6 patients with PAIVS were included in this retrospective study. They were aged 1 day to 90 days old. Study modalities included review of recordings of presentations and profiles of chest radiography, electrocardiography, echocardiography, and cardiac catheterization with angiography. Hemodynamic profiles from the echocardiography and the cardiac catheterization were analyzed.

RESULTS

Echocardiography showed severe tricuspid regurgitation, membranous atresia of the pulmonary valve, intact ventricular septum, patent ductus arteriosus, and hypoplastic right ventricle in 6 patients. The pulmonary valve annulus were 4.2 to 6.9 mm in diameters, and those of the tricuspid valve were 7.1 to 10.1 mm. Elevated serum level of cardiac enzymes were found in 1 patient with ventriculocoronary communication (VCC). At cardiac catheterization, the ratio of systolic pressure of the right ventricle to that of the left ventricle ranged from 1.43 to 2.33 before RPVV, and from 0.54 to 1.15 after RPVV (p=0.027). The pressure gradients ranged from 76 to 136 mmHg before RPVV, and from 15 to 39 mmHg after RPVV (p=0.028). The echocardiographic gradients ranged from 16 to 32 mmHg within 24 hours after RPVV, and from 15 to 50 mmHg at the follow-ups.

CONCLUSION

RPVV can be a treatment of choice for neonates with PAIVS, if there is patent infundibulum, no right-ventricular dependent coronary circulation, and adequate tricuspid valve and pulmonary valve.

Diagnosis and management of congenital coronary arteriovenous fistula in the pediatric patients presenting congestive heart failure and myocardial ischemia

PURPOSE

Four pediatric patients with congenital coronary arteriovenous fistula (CAVF) were reported to remind pediatric practitioners and cardiologists of its diagnosis and management.

MATERIALS AND METHODS

Four pediatric patients with congenital CAVF from June 1999 to November 2007 were included in this retrospective study. Study modalities included reviews of patients' profiles of clinical features, chest radiograph, Doppler echocardiography, cardiac catheterization with angiography, myocardial perfusion scan, and computed tomography.

RESULTS

All 4 patients were symptomatic. The clinical symptoms and signs were feeding problem, continuous murmur, tachycardia, tachypnea, cardiomegaly, and exertional chest pain. Myocardial enzyme was elevated in 1 patient. Echocardiography showed dilatation of the coronary artery in all 4 patients, and traced down its origin in 3 and drainage in 4. The fistulas originated from the right coronary artery in 2 patients and left coronary artery in 2, and were drained into the right ventricle in 2, right atrium in 1, and pulmonary artery in 1. Single left coronary artery was found in 1 patient. The pulmonary-to-systemic blood flow ratios ranged from 1.2 to 2.5. Transcatheter coil occlusion was successfully performed in 4 patients through a coaxial delivery system. The symptoms and signs of congestive heart failure and myocardial ischemia disappeared after the procedure.

CONCLUSION

Diagnosis of congenital CAVF could be achieved by appreciation of continuous murmur over area unusual for the ductus, and by scrupulous examination of echocardiography as well as angiography of the coronary artery through which coaxial transcatheter coil occlusion could be performed successfully.

Late-onset Enterobacter cloacae sepsis in very-low-birth-weight neonates: experience in a medical center

OBJECTIVE

The objective of this study was to review the early clinical profiles and outcomes of very-low-birth-weight (VLBW) neonates with late-onset sepsis caused by Enterobacter cloacae.

METHODS

We reviewed the medical records of VLBW neonates whose blood and/or cerebral spinal fluid yielded E. cloacae after 3 days of hospitalization in our neonatal intensive care unit.

RESULTS

From January 1997 to December 2006, a total of 29 episodes of E. cloacae infection occurred in 28 VLBW neonates. The onset of E. cloacae infection ranged from 4 to 70 days (27.4 +/- 9.6) days after birth. The most common symptoms and signs of sepsis were desaturation (58.6%), tachycardia (58.6%), apnea (55.2%), unstable body temperature (48.3%), and decreased activity (44.8%). The infected neonates had an average of four kinds of symptoms in each sepsis episode. The most common laboratory findings in VLBW neonates with E. cloacae sepsis were thrombocytopenia (65.5%), C-reactive protein > or = 1 mg/dL (55.2%), band-form neutrophils > or = 5% (41.4%), and leucopoenia (20.7%). Empirical intravenous antibiotic therapy comprising piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) was successful in the early treatment of 24 episodes of E. cloacae sepsis in 25 patients. Three neonates (10.7%) died due to E. cloacae sepsis. Four neonates (14.3%) developed E. cloacae meningitis, and two of them developed brain abscesses.

CONCLUSIONS

E. cloacae infection in VLBW neonates usually presents with nonspecific symptoms and signs. Early recognition of sepsis and empirical combination of piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) may be useful for treatment of sepsis caused by this highly virulent pathogen.

Exchange transfusion using peripheral vessels is safe and effective in newborn infants

OBJECTIVES

The purpose of this study was to compare the efficiency and safety of exchange transfusion by using peripheral arteries and veins with that of conventional exchange transfusion via the umbilical vein in treating neonatal pathologic hyperbilirubinemia.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of all neonates who had undergone exchange transfusion at our institution from January 1995 to December 2006. Causes of jaundice, efficiency of exchange transfusion in lowering serum bilirubin concentrations, adverse events, and outcomes were recorded. Data were compared between neonates who had undergone exchange transfusion via the peripheral arteries and veins method and those who had undergone exchange transfusion via the umbilical vein method. Data were also compared between stable neonates (body weight > 1500 g without medical problems other than jaundice) and unstable neonates.

RESULTS

A total of 123 exchange-transfusion procedures were performed in 102 neonates in the 12-year study period: 24 were performed via the umbilical vein method and 99 via the peripheral vessels method. A total of 87 procedures were performed in 75 stable neonates and 36 in 27 unstable neonates. There was no significant difference in reduction of serum bilirubin level from circulation or the duration of procedures between the 2 methods. Eight neonates died before discharge, but none of the deaths seem to have been attributable to the exchange-transfusion procedure. Severe adverse events occurred more commonly in the umbilical vein group than the peripheral arteries and veins group in the stable neonates. All of the severe and minor events resolved completely without noticeable sequelae before discharge.

CONCLUSIONS

Exchange transfusion using peripheral arteries and veins is efficient and effective in reducing serum bilirubin from circulation and is associated with few adverse events. This method should be considered for all neonates requiring exchange transfusion for treatment of neonatal hyperbilirubinemia.

Major determinants and long-term outcomes of successful balloon dilatation for the pediatric patients with isolated native valvular pulmonary stenosis: a 10-year institutional experience

PURPOSE

We report herein major determinants and long-term outcomes of balloon dilatation (BD) for 27 pediatric patients with isolated native valvular pulmonary stenosis (VPS).

MATERIALS AND METHODS

From May 1997 to May 2003, 27 pediatric patients with VPS (pressure gradients >or= 40 mmHg) were enrolled in this retrospective study. Single-balloon maneuver was applied in 26 patients, and double-balloon maneuver in 1. After BD, the pressure gradients were documented simultaneously by pullback maneuver by cardiac catheterization and echocardiography within 24 hours, at 1-month, 3-month, 1-year, and 4-to-10-year follow-ups.

RESULTS

Before BD, the echocardiographic gradients ranged from 40 to 101 mmHg (61+/-19, 55), and from 40 to 144 mmHg (69+/-32, 60) by pressure recordings. After BD, the gradients ranged from 12 to 70 mmHg (29+/-13, 27) by pressure recording (p<0.001), and from 11 to 64 mmHg (27+/-12, 26) by echocardiography within 24 hrs (p<0.001). The ratios of the systolic pressure of the right ventricle to those of the left ventricle were 55 to 157% (89+/-28, 79%) before BD, and 30 to 79% (47 +/- 13, 42%) after BD (p<0.001). Follow-up (7.7+/-5.7, 4.5 years) echocardiographic gradients ranged from 11 to 61 mmHg (25+/-11, 24). Two patients did not have immediate success owing to infundibular spasm. Improved right ventricular compliance could be accounted for the ultimate success in these 2 patients. The ultimate successful rate was 100%.

CONCLUSION

BD can achieve excellent long-term outcomes in the pediatric patients with isolated native VPS.