Neonatal Morbidity Pattern among Infants Born to Diabetic Mothers at Jamhouria Hospital, Benghazi- Libya

Introduction: Diabetes has long been associated with maternal and perinatal morbidity and mortality. The infant of a diabetic mother have higher risks for serious problems during pregnancy and at birth. Problems during pregnancy may include increased risks of abortions and stillbirths. Abnormal fetal metabolism during pregnancy complicated by maternal diabetes mellitus results in multiple neonatal sequallae, including abnormalities of growth, glucose and calcium metabolism, hematologic status, cardio- respiratory function, bilirubin metabolism, and congenital anomalies. The causes of the fetal and neonatal sequallae of maternal diabetes are Multifactorial. However, many of the perinatal complications can be traced to the effect of maternal glycemic control on the fetus & can be prevented by appropriate periconceptional & prenatal care. Objective: to describe the morbidity pattern among infants of diabetic mothers (IDMs) either gestational or preconception diabetes mellitus. Methods: A cross sectional study was conducted in Jamhouria hospital/ neonatal ward & enrolled 120 consecutive infants born to diabetics mother either gestational or preconception diabetes mellitus over one year period. Results: 120 babies were diagnosed as IDMs and were admitted to Neonatal intensive care unit, male, female, 74(60.8%) were gestational diabetes, and 46 (38.3%) with preconception diabetes, full term comprise 98 cases (81.6%) while premature were 22 cases (18.3%). For birth weight 20 case [16.7%} were low birth weight, macrosomia represent 16 case (13.3%). Most common congenital anomalies was cardiac lesion 36 cases, for GDM 18 case =24.3% were PCDM 18 case around 40.0%. Central nervous system 11 case (9.1%) all of them dilated ventricular system& only 2 of them need surgical intervention with shunt. Gastrointestinal anomalies 4 cases {3.4%} 2 of them ectopic anus & 2 short bowel syndrome. Most common metabolic disturbance was Hypocalcemia 17 case (14.1%), followed by hypoglycemia 11 case (9.1%), followed with hyper bilirubinemia 3 cases (2.5%) Followed by Respiratory distress syndrome 26 case (21.6%), 17 case hyaline membrane disease (14.1%) ,transient tachypnea of neo born 9 cases (7.5%) , Birth trauma 3 cases Erb,s palsy one of them birth asphyxia. Conclusion: Most common type of diabetes in pregnancy is gestational diabetes, and most common congenital anomalies is the cardiac lesion & the most common metabolic disturbance is the hypocalcemia. Macrosomia associated with large birth weight as well as birth trauma. Large for gestational age and hypoglycemia associated mainly with poor maternal glycemic control.

The Value of Transthoracic Echocardiography in the Detection of Extra-Cardiac Lesions

Objective: Transthoracic echocardiography (TTE) is generally recognized as the top choice for detecting myocardial and cardiac cavity lesions. Sonographers mostly focus on myocardial, cardiac cavity and cardiac hemodynamics, whereas the abnormal extra-cardiac lesions are always unrecognized. The aim of this study was to investigate the ultrasonic image features in abnormal extra-cardiac lesions and the value of TTE in the detection of extra-cardiac lesions.Methods: 49 cases of abnormal extra-cardiac lesion detected by TTE from January 2014 to December 2019 were collected, which were confirmed by pathology. The two-dimensional ultrasonic characteristics and the relationships with the cardiac and great vessels were summarized on the basis of multi-view by TTE. All patients were also performed by computed tomography (CT). Results: In 49 patients with abnormal extra-cardiac lesions, 37 malignant cases and 12 benign cases were included. There were 41 cases (41/49,86.67%) of mediastinal lesions and 8 cases (8/49,16.33% ) of lung lesions. The maximum diameter ranged from 3.2cm to 13.66cm, and the median diameter was about 7.4cm, among which 29 cases (29/49,59.18%) were larger than 5cm. 4 cases (4/49, 4.08%) of cystic anechoic lesions were pericardial cyst. 2 cases (2/49, 4.08%) of cystic-solid echogenic lesions were teratoma. The remaining 45 cases (45/49, 91.84%) presented as solid hypoechoic or heterogeneous masses. 6 cases compressed the heart and 21 cases encroached on the heart and vessels. Diagnosis coincidence rates of TTE and CT were respectively 77.55% and 93.88%, with a statistical difference (p =0.012).Conclusion: Although the diagnostic coincidence rate of TTE is slightly lower than that of CT, TTE has certain diagnostic value for extra-cardiac lesions.

Rebuild-up Effect on Superficial Cardiac Lesion Surrounded by Low-density Lungs: Volumetric Modulated Arc Therapy (VMAT) Planning Study Using 3-D Printed Phantom for Ventricular Tachycardia (VT)

The study aimed to evaluate dose distributions on the superficial cardiac lesion surrounded by low-density lungs. We fabricated the 3-D printed cardiac phantom to insert in a multipurpose lungman phantom (KYOTO KAGAKU, Japan) for simulating a stereotactic body radiation therapy (SBRT) in ventricular tachycardia (VT) treatment. The cardiac phantom consists of 11 slabs with 1-cm intervals and is designed to insert radiochromic film (Gafchromic EBT3, Ashland Advanced Materials, Bridgewater, NJ) for film dosimetry. We used film dosimetry scanners (DosimetryPRO Advantage Red, Vidar Systems Corporation, Herndon, VA) with dedicated film dosimetry software (OP-IMRT, ver.1.6, IBA dosimetry, Germany). Volumetric modulated arc therapy (VMAT) technique was applied to optimize the dose distribution using the anisotropic analytic algorithm (AAA) in a radiation treatment planning (RTP) system (Eclipse v. 13.6, Varian, Palo Alto, CA). We used the 6-MV and 15-MV photon energies from a LINAC (Clinac iX, Varian, Palo Alto, CA) to investigate the planning target volume (PTV) under-dose effects due to the inner dose rebuild-up by energy dependence. The dose distributions in the VMAT plans with 6-MV and 15-MV showed good competitive coverages of the cardiac lesion without any severe underdose pattern. On the other side, the film dosimetry results showed significant dose variations near the interface of the cardiac lesion surrounded by low-density lung. The differences between the planning and the film dosimetry results revealed pretty well in both photon energies. The maximum dose differences in the cardiac PTV were ranged from 4.1–7.7% and 4.1–8.1% for 6-MV photon beams and 15-MV photon beams. Furthermore, EBT3 film measurements showed that the widths of 50% of profiles were reduced by 1.3 cm and 2.3 cm on 6-MV photon beams and 15-MV photon beams, respectively. In addition, 3-D printing techniques enabled quite challengeable dose measurements to reveal this kind of dose discrepancies in humanoid structures. This study showed that clinical cases like VT SBRT surrounded by severe inhomogeneous matter could induce wrongly to estimate appropriate dose delivery and to evaluate reasonable clinical outcomes.

Post-infectious inflammatory syndrome associated with SARS-CoV-2 in a paediatric patient with Down syndrome

Neurological complications of SARS-CoV-2 continue to be recognised. In children, neurological phenomenon has been reported generally in the acute infectious period. It is possible that SARS-CoV-2 could trigger an immune-mediated post-infectious phenomenon. Here, we present a unique case of post-infectious marantic cardiac lesion causing cerebrovascular accident in a patient with Down syndrome.

Reproductive health conversations in adolescents with CHD

Background: Reproductive issues as related to CHD must be discussed in the clinic and at home. Providers can ensure that correct information is imparted to the adolescent and encourage mothers to provide support and guidance to the adolescent. The level to which these conversations occur is unknown. Methods: A survey distributed to female adolescent/mother dyads assessed self-reported conversations with the healthcare provider and between each other about reproductive health topics. A clinician survey was completed to assess CHD diagnosis, risk of hormonal contraception, and pregnancy risk. Results: Among 91 dyads, 33.0% of adolescents and 42.9% of mothers reported discussing recurrence risk of CHD with the provider. In regard to the cardiac lesion affecting a baby, 30.7% of adolescents and 28.7% of mothers reported discussing this with a provider. Significantly less adolescents and mothers reported discussing the risks of hormonal contraception and pregnancy with a provider. In assessing conversations between adolescents and mothers, only 44.2% of adolescents and 52.3% of mothers reported discussing with each other the safety of using birth control and 46.5% of adolescents and 64.0% of mothers reported discussing the safety of pregnancy. Conclusions: Adolescents with CHD and their mothers report low rates of reproductive health-related conversations with the healthcare provider, and mothers report low rates of having these conversations with their daughters. These topics should be discussed at each appointment with the cardiologist and must be encouraged to continue at home.

Stereotactic Body Radiation Therapy (SBRT) for a Patient with a Myocardial Metastasis: A Case Report

Metastatic lesions of the heart are rare but have the potential to cause significant morbidity. We describe the case of a patient with renal cell carcinoma who presented with shortness of breath and palpitations and was found to have a metastatic myocardial lesion causing arrythmia. He received stereotactic body radiation therapy (SBRT) to alleviate symptoms and provide local control. SBRT planning was executed using a four-dimensional computed tomography (4DCT) scan to account for respiratory and cardiac motion. Images from a planning magnetic resonance imaging (MRI) scan and a gated diagnostic MRI scan of the heart were fused with the 4DCT to assist with delineating the tumour. A dose of 30 Gy in five fractions was delivered without incident. The patient’s cardiac MRI at two months post-treatment showed stability of his cardiac lesion. He subsequently died of distant disease progression, without any recurrence of his cardiac symptoms. SBRT may be considered for patients who present with a symptomatic metastatic cardiac lesion.

FETAL ECHOCARDIOGRAPHY: 12 YEARS EXPERIENCE AT AFIC /NIHD

Objective: To determine the frequency of congenital cardiac lesions in pregnant women reporting for fetal echocardiogram and correlate with obstetrical risk factors. Study Design: Descriptive cross-sectional study. Place and Duration of Study: To be conducted at pediatric cardiology and obstetrical unit of AFIC/NIHD and CMH Rawalpindi, from Jan 2009 to Jan 2020. Methodology: Pregnant women referred for fetal echocardiogram from 19-49 years of age were enrolled. Echo was done between 20 to 36 weeks gestation. Primary outcome was the nature of cardiac lesion and gestation at diagnosis. Neonatal scan was done at follow up to confirm cardiac diagnosis. Secondary outcome was obstetrical risk factors which were the reason for referral. This included age consanguinity, family history, previous history of intrauterine death or early neonatal death, maternal and paternal diseases. Data was collected and analyzed n frequencies and percentage. Chi-square was applied for association between variable and p-valve 0.05 was considered significant. Results: A total of n=967 pregnant women referred to outpatient department for fetal echocardiogram. Congenital cardiac lesion were detected in n=83 patients. Majority of patients had CAVSD (1.2%) CCAVB (1.2%) followed by ASD (1.1%) VSD (0.9%) Abnormal heart rate (0.8%) Single ventricle (0.3%). Most significant maternal age group was between 21 to 30 and 30-40 years (43.7 and 46.2%). Only 3% below 20 years and 6.7% above40 years of age. Most important maternal risk factor was previous off spring 0.5% past family history 0.3% and abnormal obstetrical ultrasound 0.3% Followed by maternal diabetes 0.1% and maternal hypertension 0.1%. The yield of detection of congenital cardiac lesions was 8.3%. Conclusions: Congenital cardiac diseases are the second most common congenital anomaly and huge burden n pediatric population. Timely diagnosis and referral can be lifesaving.

RUPTURED SINUS OF VALSALVA ANEURYSM (SOVA): A CASE REPORT

Sinus of Valsalva Aneurysm is a rare anomaly of the cardiovascular system. It may be acquired or congenital and may also be associated with another cardiac lesion. Acute onset of dyspnea is experienced when the aneurysm ruptures. Diagnosis is reached by echocardiography and Cardiac MRI. The treatment is surgical repair. This paper presents the case of a 24-year old male with acute onset of symptoms caused by a ruptured sinus of Valsalva Aneurysm.

Does high-variation training facilitate transfer of training in paediatric transthoracic echocardiography?

Background: Factors that facilitate transfer of training in paediatric echocardiography remain poorly understood. This study assessed whether high-variation training facilitated successful transfer in paediatric echocardiography. Methods: A mixed-methods study of transfer of technical and interpretive skill application amongst postgraduate trainees. Trainees were randomised to a low or high-variation training group. After a period of 8 weeks intensive echocardiography training, we video-recorded how trainees completed an echocardiogram in a complex cardiac lesion not previously encountered. Blinded quantitative analysis and scoring of trainee performance (echocardiogram performance, report, and technical proficiency) were performed using a validated assessment tool by a blinded cardiologist and senior cardiac physiologist. Qualitative interviews of the trainees were recorded to ascertain trainee experiences during the training and transfer process. Results: Sixteen trainees were enrolled in the study. For the cumulative score for all three components tested (echocardiogram performance, report, and technical proficiency), χ2 = 8.223, p = .016, which showed the high-variation group outperformed the low-variation group. Two common themes which assisted in the transfer emerged from interviews are as follows: (1) use of strategies described in variation theory to describe abnormal hearts, (2) the use of formative live feedback from trainers during hands-on training. Conclusion: Training strategies exposing trainees to high-variation training may aid transfer of paediatric echocardiography skills.

In Hospital Outcomes after Bidirectional Cavopulmonary Anastomosis: 18 Year Experience from a Single Center

Background: Bidirectional cavopulmonary shunt (BCPS) is used for the interim palliation of a variety of cyanotic cardiac lesions. It is a standard palliative step for patients with functionally univentricular hearts in hope of achieving Fontan completion. At our center, first case of BCPS was performed on February 7, 2002. Here, we share our experience with BCPS over last 18 years. Methods: This is a retrospective analysis of all patients undergoing BCPS from February 2002 to July 2019. Patients who underwent BCPS as a part of one-and-half ventricular repair for Ebstein’s anomaly were excluded. Baseline, intraoperative, and postoperative variables were collected from hospital records. Results: A total of 326 patients with mean age of 5.7±5.8 years (median 3.5 years; range: 1.5 months-32 years) underwent BCPS over last 18 years. Majority (61%) were males. Double outlet right ventricle (DORV) was the most common primary cardiac lesion (30%) followed by tricuspid atresia (23%). Mean ICU stay was 3.9±4.8 days, with hospital stay of 7.8±5.9 days. In-hospital mortality was 15%. Patients who died had low body weight (11.8±10.7 kg vs 16.0±11.6 kg; p=0.019), and longer cardiopulmonary bypass time (101±64 min vs 76±42 min; p=0.001). Oxygen saturation improved significantly at the time of discharge (79.2±9.5% vs 68.6±13.7%; p=0.000). Conclusion: This is the first report of its kind to analyze the outcomes of BCPS in our center. We have discussed the evolution of BCPS surgery in our center and presented our outcomes. Our in-hospital mortality remains high, and we need to strive towards reducing the mortality.