Thomas W. Riggs

Doppler echocardiographic evaluation of left ventricular diastolic function in adolescents with diabetes mellitus

Doppler echocardiograms of the mitral valve were recorded along with electrocardiograms and respirations from 20 diabetics and 16 normal subjects, all aged 10 to 15 years. E and A areas (the components of the total velocity-time integral in the early passive period of ventricular filling [E] and the late active period of atrial emptying [A], respectively), the peak E and A velocities (cm/s) and the 1/3 area fraction (or the proportion of filling in the first 1/3 of diastole) were measured. Each of the following was significantly greater for the normal subjects versus diabetic patients: peak E (96 +/- 14 vs 81 +/- 14 cm/s, p less than 0.005), E/total area (0.74 +/- 0.04 vs 0.69 +/- 0.06, p less than 0.005) and peak E/A velocity ratio (2.38 +/- 0.55 vs 1.92 +/- 0.55, p less than 0.05). The mean heart rates and ages were not significantly different for the 2 groups. The remaining parameters (peak A velocity, A/total area, E/A area, and 1/3 area fraction) were also not significantly different for the 2 groups. This study is the first to demonstrate diastolic dysfunction in pediatric patients with diabetes and may indicate abnormalities of ventricular relaxation or compliance in diabetes mellitus.

Fetal cardiac asymmetry : A marker for congenital heart disease

OBJECTIVE To determine the sensitivity of prenatally detected fetal cardiac asymmetry as a sonographic marker for congenital heart disease. METHODS The normal ratios of pulmonary artery to aorta diameters and of right ventricle to left ventricle diameters were derived from normal fetuses scanned at 17 weeks or more in a 65-month period. Cross-sectional diameters of cardiac ventricles and great arteries were measured at the level of the valves at the time of the scan. Fetuses with confirmed cardiac anomalies detected prenatally during the study were examined to identify how many had cardiac asymmetry, determined by abnormal ratios. RESULTS Linear regression analysis of the group of 881 normal fetuses showed the normal pulmonary artery to aorta diameter ratio remained constant throughout pregnancy and the normal right ventricle to left ventricle ratio increased slightly with progressing gestational age. The 90% confidence intervals were 0.79, 1.24 for the right ventricle to left ventricle ratio and 0.84, 1.41 for the pulmonary artery to aorta ratio. Of the 73 fetuses with abnormal hearts, 66% had either ventricular or great artery asymmetry (at least one of the two ratios was abnormal). However, if no asymmetry was present, the cardiac defect was more likely to be a minor one. CONCLUSION Cardiac asymmetry was present in two-thirds of fetuses with cardiac anomalies diagnosed prenatally. If cardiac asymmetry is found, a more thorough examination of the fetal heart is indicated.

Physiologic peripheral pulmonic stenosis in infancy

We studied 14 premature infants with the clinical diagnosis of peripheral pulmonic stenosis (PPS) and 15 normal full-term neonates by echocardiographic Doppler examinations. The PPS group had an average main pulmonary artery (PA) diameter similar to the control group (0.91 vs 0.96 cm, difference not significant), but had smaller branch PA diameters: right PA = 0.41 vs 0.50 cm, p less than 0.001, and left PA = 0.41 vs 0.49 cm, p less than 0.001. The PPS group also had greater peak velocities in the main PA (76 vs 63 cm/s, p less than 0.05), right PA (193 vs 118 cm/s, p less than 0.001) and left PA (187 vs 123 cm/s, p less than 0.001). Similarly, the ratio of peak velocity in the branch/main PA was greater for the PPS group: right/main PA peak velocity = 2.91 vs 1.92, p less than 0.01, and left/main PA peak velocity = 2.73 vs 1.99, p less than 0.05. The calculated right ventricular output for the PPS group was more than the control group: 437 vs 261 ml/min/kg, p less than 0.001. Hematocrits were not done on the control group, but the PPS group had an average hematocrit which was low (34%). It is concluded that patients with PPS have mild underdevelopment of the PA branches, with consequent increased flow velocity and turbulent flow. This turbulent flow may be contributed to by increased cardiac output and mild anemia.

The relationship of newborn adiposity to fetal growth outcome based on birth weight or the modified neonatal growth assessment score.

Objectives: (1) Develop reference ranges of neonatal adiposity using air displacement plethysmography. (2) Use new reference ranges for neonatal adiposity to compare two different methods of evaluating neonatal nutritional status. Methods: Three hundred and twenty-four normal neonates (35–41 weeks post-menstrual age) had body fat (%BF) and total fat mass (FM, g) measured using air displacement plethysmography shortly after delivery. Results were stratified for 92 of these neonates with corresponding fetal biometry using two methods for classifying nutritional status: (1) population-based weight percentiles; and (2) a modified neonatal growth assessment score (m3NGAS51). Results: At the 50th percentile, %BF varied from 7.7% (35 weeks) to 11.8% (41 weeks), while the corresponding 50th percentiles for total FM were 186–436 g. Among the subset of 92 neonates, no significant differences in adiposity were found between small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA) groups using population-based weight standards. Classification of the same neonates using m3NGAS51 showed significant differences in mean %BF between corresponding groups. Conclusions: Population-based weight criteria for neonatal nutritional status can lead to misclassifications on the basis of adiposity. A neonatal growth assessment score, that considers the growth potential of several anatomic parameters, appears to more effectively classify under- and over-nourished newborns.

An analysis of fine needle aspiration versus core needle biopsy in clinically palpable breast lesions: a report on the predictive values and a cost comparison

BACKGROUND Although fine-needle aspiration (FNA) is an established tool in the biopsy of breast masses, there has been a trend toward using core-needle biopsy (CNB). The aim of this study was to determine whether FNA has comparable predictive value with CNB and whether FNA is more cost effective. METHODS A retrospective review was conducted on 162 patients who underwent either FNA or CNB of palpable breast lesions and had histologic confirmation with surgical biopsy in calendar year 2005. RESULTS There were no false-positives or false-negatives in either group. The sensitivity, specificity, and positive predictive value for FNA were 89%, 98%, and 94%, respectively. CNB had sensitivity, specificity, and positive predictive value of 100%, 90%, and 93%, respectively. The cost to perform FNA was

Spontaneous closure of atrial septal defects in premature vs. full-term neonates.

166.34, compared with

Impact of the New 16-Hour Duty Period on Pediatric Interns’ Neonatal Education

477.92 for CNB. CONCLUSIONS FNA and CNB had comparable predictive value, with FNA being more cost effective.

Dizygotic twins concordant for truncus arteriosus.

Abstract. Our hypotheses were that the following factors influenced closure of atrial septal defects (ASDs) detected in neonates: estimated gestational age (EGA), the presence of a persistent ductus arteriosus (PDA), severity of pulmonary disease, gender, and the initial size of the ASD. Our population consisted of 82 newborns (38 premature and 44 term) who were found before the age of 1 month to have an ASD. Closure of ASDs was analyzed using both Kaplan–Meier survival analysis and the Cox proportional hazards model, each with the five covariates. The hazard ratio (or ratio of instantaneous closure rates) of term vs preterm infants was 3.60 (95% CI = 1.80–7.20), whereas the hazard ratio for infants with a PDA (compared to infants with no PDA) was 2.41 (95% CI = 1.28–4.54). Multivariate analysis showed that each of these terms (PDA and EGA) were independent predictors of ASD closure. The hazard ratio of ASD closure for each of four levels of pulmonary disease was 0.632 [95% CI = 0.453–0.881]. We conclude that the majority of neonatal ASDs will close, with EGA and PDA acting as important influences on closure.

A quadricuspid pulmonic valve diagnosed in a live newborn by two-dimensional echocardiography.

Objective. To assess the impact of the 16-duty hour restriction on pediatric interns’ neonatal education. Method. Survey of interns clinical and educational experiences during their neonatal rotations. Results. A total of 316 respondents in 2011, who worked >16 hours, were compared with 509 respondents in 2012, who worked ≤16 hours. The average work week decreased from 67.3 ± 9.6 to 59.3 ± 8.1 hours (P < .0001). The 2012 cohort attended fewer didactic lectures (−16%, P < .0001), grand rounds (−27%, P < .0001), and mock resuscitations (−16%, P < .005). There were no significant differences in the number of (1) patients on service, (2) deliveries attended, or (3) procedures. There was no significant difference in the median number of correct responses (4) on 10 knowledge-based multiple-choice questions. Conclusions. The decrease in duty hours was achieved without significantly affecting interns’ knowledge or clinical experience.

Abnormal right ventricular filling in patients with dilated cardiomyopathy

Persistent truncus arteriosus (TA) is an uncommon congenital cardiovascular malformation, which comprises between 0.4% and 4% of all congenital heart defects. Occurrence of TA in siblings has been reported infrequently. Twins concordant for isolated TA appear to have been reported only once previously. In this paper, we describe dizygotic twin females who were concordant for isolated TA.