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A 29-month-old girl was admitted with a 2-week history of cough followed by complaints of abdominal pain, vomiting, anorexia and easy fatigability. On examination, she was noted to be tachypneic and have hepatomegaly. Chest X-ray revealed cardiomegaly and echocardiogram showed dilated left ventricle with severely reduced function and significant mitral valve regurgitation. She was transferred to our institution with an initial diagnosis of acute myocarditis, which was confirmed subsequently on cardiac biopsy and was attributed to be because of parvovirus infection. Initial medical management, which included diuresis and afterload reduction failed to improve her symptoms, and 38 days postadmission a decision to place a Berlin EXCOR LVAD (25 ml pump, 9 mm apical cannula, and 5 mm aortic cannula) was made. Postoperative transesophogeal echocardiogram demonstrated decompression of the left ventricle and no evidence of intracardiac thrombus.Post-LVAD placement, the patient did well and was successfully extubated, advanced to full enteral diet and an aggressive rehabilitation program was initiated. Anticoagulation management of the LVAD was accomplished with twice daily enoxaparin (anti-factor Xa level was 1 on the day of stroke with levels maintained 0.6-1.1 during the previous 2 weeks), two-times-per-day aspirin and four-times-per-day dipyridamole (100% inhibition of

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BackgroundThe significance of reduced vitamin D (25-OHD) to skeletal health, as assessed by radiological changes and fracture risk, is not known in detail. The uncertainty of this nutritional interaction becomes critical for instance in cases of potential non-accidental fracture. In order to provide an insight into this area we studied a paediatric group at high risk of low vitamin D levels.AimsWe aimed to estimate the incidence of radiological bony changes in patients attending a paediatric tuberculosis clinic, many of whom have chronically low vitamin D levels. Secondary outcomes were to assess whether serological markers of bone health can be used to identify those at greater risk of osteopenia and rickets.MethodsChildren attending a paediatric TB clinic between 01/01/2008 and 31/12/2011 had blood samples, including serum vitamin D levels, and chest radiograph taken as part of routine investigation at diagnosis. All radiographs were reported independently and retrospectively by two consultant radiologists, who were blinded to the child’s vitamin D status, on the presence of osteopenia or rickets.Results174 children were included in this study (46.6% male, median age 7 years range, 0.25–16y). At the point of diagnosis, 35 children were 25-OHD deficient (levels <25nmol/l), 57 were insufficient (levels 25–49nmol/l). During the study none of the cases suffered fracture and none had clinical evidence of rickets. Osteopenia was reported in one child by one radiologist. This child had a vitamin D level of 22 nmol/l and a raised PTH at 36.9.PTH levels were normal in 92 children, unavailable in 45 and raised in 30 children, of whom 29 had normal radiological skeletal appearances. A significant correlation between 25-OHD and PTH was identified (r=–0.371, 95% CI –0.5105 to –0.2123, p value <0.0001). Two children had hypocalcaemia with vitamin D deficiency but had normal PTH and alkaline phosphatase levels. There was no correlation between serum 25-OHD levels and alkaline phosphatase levels.ConclusionThe low incidence of radiographic bony abnormality and absence of fractures in a cohort of children with vitamin D deficiency, suggests many children with low serum vitamin D levels are unlikely to develop rickets and fractures.