Evolving management for critical pulmonary stenosis in neonates and young infants

Over the years, management of critical pulmonary stenosis in young infants has evolved from surgical reconstruction of the right ventricular outflow tract and closed pulmonary valvotomy to transcatheter balloon valvoplasty. Our study aimed at evaluating how the changing policy for management had affected the immediate and long term outcomes of babies with this cardiac lesion. Interventions were made in 34 infants at a median age of 8.5 days (2-90 days). Reconstruction of the right ventricular outflow tract reconstruction was performed in 10 patients, closed pulmonary valvotomy in 13, and balloon valvoplasty in 11. Initial procedure-related mortality was 50%, 15% and 0% respectively. Multivariate analysis revealed transannular patching of the right ventricular outflow tract, and male sex, to be significant factors for death. For the 27 survivors, the ratio of right ventricular to systemic systolic pressure decreased from 1.6 ± 0.3 to 0.3 ± 0.2 after reconstruction of the outflow tract, 1.8 ± 0.5 to 0.8 ± 0.4 after closed valvotomy, and 1.8 ± 0.6 to 0.9 ± 0.3 after balloon valvoplasty. The decrease was significantly greater after patch reconstruction (p=0.025) that required no further reinterventions. The overall rate of reintervention for the survivors was 37% (10/27). The freedom from reintervention after closed valvotomy was 82%, 64% and 51% at 1, 5 and 10 years respectively. The figure remained at 78% at both 1 and 5 years (p=0.66) after balloon valvoplasty. The higher reintervention rate for closed valvotomy corresponded to the significantly greater residual gradient across the pulmonary valve noted on follow-up (p=0.01). Reinterventions included balloon dilation (n=6), reconstruction of the outflow tract (n=4), and 1 each of ligation of an arterial duct and systemic-pulmonary arterial shunting. The risk factor for reintervention was a hypoplastic right ventricle. In conclusion, transcatheter balloon valvoplasty appears to be the optimum initial approach in view of its low mortality, efficacy at relieving the obstruction, and low rate of reintervention. © Greenwich Medical Media Ltd.published_or_final_versio

Comparing accuracy of obstetric sonography and fetal echocardiography during paediatric cardiology consultation in prenatal diagnosis of congenital heart disease

OBJECTIVE: Compare the diagnostic accuracy of fetal echocardiogram performed by obstetrician alone and that performed jointly by obstetrician and paediatric cardiologist for congenital heart disease. METHOD: All cases of suspected fetal congenital heart disease referred to Prenatal Diagnostic Clinic in ...published_or_final_versio

Using illness scripts to teach clinical reasoning skills to medical students

Background and Objectives: Most medical students learn clinical reasoning skills informally during clinical rotations that have varying quality of supervision. We conducted a randomized controlled trial to determine if a workshop that uses "illness scripts" could improve students' clinical reasoning skills when making diagnoses of patients portrayed in written scenarios. Methods: In 2007-2008, 53 fourth-year medical students were randomly assigned to either a family medicine (intervention) or psychiatry (control) clerkship at The Chinese University of Hong Kong. Students in the intervention group participated in a 3-hour workshop on clinical reasoning that used illness scripts. The workshop was conducted with small-group teaching using a Web-based set of clinical reasoning problems, individualized feedback, and demonstration of tutors' reasoning aloud. The effectiveness of the intervention was assessed using the Diagnostic Thinking Inventory (DTI) and the measurement of individual students' performance in solving clinical reasoning problems (CRP). Results: The postintervention overall DTI scores between groups were similar (mean difference 0, 95% confidence interval [CI]= -7.4 to 7.4). However, the total scores on the CRP assessment were 14% (95% CI=8% to 21%) higher in the intervention group than in controls. Conclusion: A workshop on illness scripts may have some benefit for improving diagnostic performance in clinical reasoning problems.link_to_OA_fulltex

22q11.2 deletion syndrome in adult Chinese Patients with Conotruncal Anomalies: dysmorphisms, clinical features and underdiagnosis

Poster Presentation (Doctor’s Session)22q11.2 deletion syndrome (22q11.2DS) is a multi-systemic disorder with high phenotypic variability. Underdiagnosis in adults is common and recognition of facial dysmorphic features can be affected by patient age and ethnicity. This study aims to determine the prevalence of undiagnosed 22q11.2DS in adult Chinese patients with conotruncal anomalies and to delineate their facial dysmorphic features and extra-cardiac manifestations. We recruited consecutively 156 patients with conotruncal anomalies in an adult congenital heart disease (CHD) clinic in Hong Kong and screened for 22q11.2DS using fluorescence- PCR and fluorescence in-situ hybridisation. Assessment for dysmorphic features was performed by a cardiologist at initial screening and then by a clinical geneticist upon result disclosure. Clinical photographs were taken with consent and childhood photographs were collected. Eighteen patients (11.5%) were diagnosed with 22q11.2DS, translating into 1 previously unrecognised diagnosis of 22q11.2DS in every 10 adult patients with conotruncal anomalies. While dysmorphic features were detected by our clinical geneticist in all patients, only two-thirds were considered dysmorphic by our cardiologist upon first assessment. Evolution of facial dysmorphic features was noted with age. Extra-cardiac manifestations included velopharyngeal incompetence or cleft palate (44%), hypocalcaemia (39%), neurodevelopmental anomalies (33%), thrombocytopenia (28%), psychiatric disorders (17%), epilepsy (17%) and hearing loss (17%). We conclude that under-diagnosis of 22q11.2DS in Chinese adults with conotruncal defects is common and facial dysmorphic features may not be reliably recognised in the setting of adult CHD clinic. In order to avoid missing the diagnosis, molecular testing of 22q11.2DS should be offered to patients with conotruncal defects regardless of the facial features

Faecal contamination of water and sediment in the rivers of the Scheldt drainage network

The Scheldt watershed is characterized by a high population density, intense industrial activities and intensive agriculture and breeding. A monthly monitoring (n = 16) of the abundance of two faecal indicator bacteria (FIB), Escherichia coli and intestinal enterococci (IE), showed that microbiological water quality of the main rivers of the Scheldt drainage network was poor (median values ranging between 1.4 × 103 and 4.0 × 105 E. coli (100 mL)−1 and between 3.4 × 102 and 7.6 × 104 IE (100 mL)−1). The Zenne River downstream from Brussels was particularly contaminated. Glucuronidase activity was measured in parallel and was demonstrated to be a valid surrogate for a rapid evaluation of E. coli concentration in the river waters. FIB were also investigated in the river sediments; their abundance was sometimes high (average values ranging between 2.1 × 102 and 3.3 × 105 E. coli g−1 and between 1.0 × 102 and 1.7 × 105 IE g−1) but was not sufficient to contribute significantly to the river water contamination during resuspension events, except for the Scheldt and the Nethe Rivers. FIB were also quantified in representative point sources (wastewater treatment plants) and non-point sources (runoff water and soil leaching on different types of land use) of faecal contamination. The comparison of the respective contribution of point and non-point sources at the scale of the Scheldt watershed showed that point sources were largely predominant.SCOPUS: ar.jinfo:eu-repo/semantics/publishe