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A total of 1,068 asymptomatic close contacts of patients with severe acute respiratory (SARS) from the 2003 epidemic in Hong Kong were serologically tested, and 2 (0.19%) were positive for [...]

Objective. Multiple cross-sectional physician surveys have documented poor cardiac auscultation skills. We evaluated the impact of 2 different educational interventions on pediatric resident auscultation skills. Methods. The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/ week to use a self-directed cardiac auscultation computer teaching program. Results. Resident auscultation skills on initial evaluation were dependent on training level (PGYI: 42 [+ or -] 15% correct; PGY2:53 [+ or -] 13% correct), primarily as a result of better classification of second heart sound (PGYI: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGYI: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent. Conclusions. Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training. Pediatrics 2004;113:1331-1335; auscultation, murmurs, educational intervention, computer-based learning. ABBREVIATIONS. PGY1, first year pediatric residents; PGY2, second-year pediatric residents; ASD, atrial septal defect; VSD, ventricular septal defect; PVS, pulmonary valve stenosis; BAV/AI, bicuspid aortic valve with aortic regurgitation; S2, second heart sound., Cardiac murmurs are common in pediatric patients, with an incidence of up to 90%. (1-11) Because METHODS All first-year (PGY1) and second-year pediatric residents (PGY2) were asked to participate in [...]

Background: While mismatching between donor and recipient human leukocyte antigen (HLA) alleles has been associated with increased graft loss in pediatric heart recipients, it is actually the surface amino acid structures, termed eplets, which determine the antigenicity of each HLA molecule. We hypothesized that HLA eplet mismatch analysis is a better predictor of adverse outcomes after pediatric heart transplant than conventional allele mismatch comparison. Methods: A retrospective review of the Pediatric Heart Transplant Society database identified pediatric heart recipients (<18 years at listing) with complete donor and recipient HLA typing (A, B, and DR). Imputed high‐resolution HLA genotypes were entered into HLAMatchmaker software which then calculated the number of eplet mismatches between each donor‐recipient pair. Multivariable Cox regression analysis was used to examine associations between allele or eplet mismatching and adverse outcomes. Results: Compared to those with <20 HLA class I eplet mismatches, recipients with 20 or more HLA class I eplet mismatches had an increased risk of graft loss (HR 1.46 [1.01–2.12], p =.049). HLA class I eplet mismatching was also associated with rejection (>20 mismatches: HR 1.30 [1.03–1.65], p =.030), while HLA class II eplet mismatching was associated with specified antibody‐mediated rejection (10–20 mismatches: HR 1.57 [1.06–2.34], p =.025; >20 mismatches: HR 3.14 [1.72–5.71], p <.001). Neither HLA class I nor class II allele mismatching was significantly associated with graft loss or rejection. Conclusion: Eplet mismatch analysis was more predictive of adverse post‐transplant outcomes (including graft loss and rejection) than allele mismatch comparison. Further study, including prospective high‐resolution HLA typing, is warranted. [ABSTRACT FROM AUTHOR]

Myocarditis remains a clinical challenge in pediatrics. Originally, it was recognized at autopsy before the application of endomyocardial biopsy, which led to a histopathology-based diagnosis such as in the Dallas criteria. Given the invasive and low-sensitivity nature of endomyocardial biopsy, its diagnostic focus shifted to a reliance on clinical suspicion. With the advances of cardiac magnetic resonance, an examination of the whole heart in vivo has gained acceptance in the pursuit of a diagnosis of myocarditis. The presentation may vary from minimal symptoms to heart failure, life-threatening arrhythmias, or cardiogenic shock. Outcomes span full resolution to chronic heart failure and the need for heart transplantation with inadequate clues to predict the disease trajectory. The American Heart Association commissioned this writing group to explore the current knowledge and management within the field of pediatric myocarditis. This statement highlights advances in our understanding of the immunopathogenesis, new and shifting dominant pathogeneses, modern laboratory testing, and use of mechanical circulatory support, with a special emphasis on innovations in cardiac magnetic resonance imaging. Despite these strides forward, we struggle without a universally accepted definition of myocarditis, which impedes progress in disease-targeted therapy. [ABSTRACT FROM AUTHOR]