Aortopulmonary size discrepancy is not a contraindication to the pediatric Ross operation

BACKGROUND

Modification of the aortic annulus or the ascending aorta, or both, may be required in pediatric patients undergoing the Ross operation. The fate of these autografts remains uncertain.

METHODS

Retrospective review of 15 patients undergoing Ross operation without aortic annular modification (group 1), 11 patients requiring annular reduction (group 2, n = 11), and 8 patients requiring annular enlargement (group 3, n = 8). Autograft function and dimensions were evaluated by echocardiography.

RESULTS

Autograft insufficiency was less than or equal to mild in 33 patients and moderate in 1 patient. The annulus body surface area ratio increased in group 1 from 19.7 +/- 5 to 20.3 +/- 5 mm/M2 (p = 0.8). The average annular reduction in group 2 was 5 +/- 1.5 mm, and 10 of 11 patients required reduction of the ascending aorta (mean 11 +/- 5 mm). The annulus body surface area ratio increased from 18.6 +/- 7 to 20.5 +/- 9 mm/M2 (p = 0.2). The mean augmentation in annulus diameter in group 3 was 6 +/- 4 mm; the annulus body surface area ratio decreased from 23.7 +/- 14 to 20.3 +/- 8 mm/M2 (p = 0.5).

CONCLUSIONS

We continue to offer the Ross operation to pediatric patients even when aortic annular or ascending aortic size discrepancies mandate surgical modifications.

Evaluation of the prognosis of in vitro fertilization pregnancies with initially low serum human chorionic gonadotropin levels

OBJECTIVE

The objective of this study was to investigate the prognostic significance of initially low serum early human chorionic gonadotropin levels in in vitro fertilization pregnancies that progress to an intrauterine gestational sac.

STUDY DESIGN

This retrospective cohort study compared 65 in vitro fertilization pregnancies with an initial human chorionic gonadotropin value at 4 weeks of < or =20 mIU/mL with 130 pregnancies with human chorionic gonadotropin values >20 mIU/mL. All pregnancies had a singleton intrauterine sac at 6 weeks' gestational age. Spontaneous abortion rates and pregnancy complications were compared.

RESULTS

Women with a low initial serum human chorionic gonadotropin level showed a statistically significant increase in first-trimester pregnancy loss (36.5% vs 9.2%; odds ratio, 5.7; 95%; confidence interval, 2.6, 12.4; P <.0001). Once pregnancies progressed to 13 weeks, there were no significant differences.

CONCLUSIONS

In vitro fertilization pregnancies with a low initial human chorionic gonadotropin value, despite progressing to a gestational sac, are at an increased risk of spontaneous abortion.

Review of policies and guidelines on infant feeding in emergencies: common ground and gaps

Recent crises in regions where exclusive breastfeeding is not the norm have highlighted the importance of effective policies and guidelines on infant feeding in emergencies. In 1993, UNICEF compiled a collection of policy and guideline documents relating to the feeding of infants in emergency situations. In June 2000 Save the Children, UK, UNICEF and the Institute of Child Health undertook a review of those documents, updating the list and identifying the common ground that exists among the different policies. The review also analysed the consistency of the policy framework, and highlighted important areas where guidelines are missing or unclear. This article is an attempt to share more widely the main issues arising from this review. The key conclusions were that, in general, there is consensus on what constitutes best practice in infant feeding, however, the lack of clarity in the respective responsibilities of key UN agencies (in particular UNICEF, UNHCR and WFP) over issues relating to co-ordination of activities which affect infant-feeding interventions constrains the implementation of systems to support best practice. Furthermore, the weak evidence base on effective and appropriate intervention strategies for supporting optimal infant feeding in emergencies means that there is poor understanding of the practical tasks needed to support mothers and minimise infant morbidity and mortality. We, therefore, have two key recommendations: first that the operational UN agencies, primarily UNICEF, examine the options for improving co-ordination on a range of activities to uphold best practice of infant feeding in emergencies; second, that urgent attention be given to developing and supporting operational research on the promotion of optimal infant-feeding interventions.

From policy to practice: challenges in infant feeding in emergencies during the Balkan crisis

The preparation and dissemination of policy statements are necessary but insufficient to prevent the inappropriate use of infant-feeding products in emergencies. The widespread failure of humanitarian agencies operating in the Balkan crisis to act in accordance with international policies and recommendations provides a recent example of the failure to translate infant-feeding policies into practice. This article explores the underlying reasons behind the failures which include: (1) the weak institutionalisation of policies; (2) the massive quantities of unsolicited donations of infant-feeding products: (3) the absence of monitoring systems; (4) inadequate co-ordination mechanisms; (5) the high costs of correcting mistakes; and (6) the cumulative effects of poor practice. Efforts to uphold best practice during the crisis are also documented. Finally, the article identifies actions that could be undertaken in advance of and during future emergencies to enhance the application of infant feeding policies in emergencies.

Determination of low-molecular-mass carboxylic acids in atmospheric aerosol and vehicle emission samples by capillary electrophoresis

A method is developed for the determination of a large number of airborne and vehicle-emitted low-molecular-mass mono- and dicarboxylic acids using capillary electrophoresis with indirect UV detection. A background electrolyte (BGE) consisting of 2,6-naphthalenedicarboxylic acid and tetradecylmethylammonium bromide, adjusted to pH 6.2 with 2,2-bis(hydroxymethyl)-2,2',2"-nitrilotriethanol, is employed. Separations are robust using the buffered BGE, proper rinse steps, and constant current mode with migration time variations less than 3% RSD on a day-to-day basis, using different capillaries and performed by different analysts. Detection limits are at the tens of microg/l level using pressure injection. A comparison of the CE method with ion chromatography is also made.

Thromboprophylaxis using a low molecular weight heparin delays fracture repair

Low molecular weight heparins are significantly superior to unfractionated heparin or warfarin in the prevention of thromboembolic episodes associated with orthopaedic surgery. Therapeutic doses of heparin and warfarin have been shown to delay bone repair in a rabbit model. The current study investigated the effect of prophylactic administration of a low molecular weight heparin, enoxaparin, on the healing of a closed rabbit rib fracture. Fracture healing was assessed using histomorphometric, histologic, and immunohistochemical methods at 3, 7, and 14 days, and biomechanical testing with torsional loading was assessed after 21 days. Bone repair was significantly attenuated at all times in animals receiving subcutaneous enoxaparin compared with that of the control animals. Numerous putative mechanisms for this phenomenon are discussed, and additional studies are proposed to elucidate the effects of this pharmacologically diverse group of compounds on all aspects of bone physiology and repair.

Phasic and enduring negative symptoms in schizophrenia: biological markers and relationship to outcome

Negative symptoms have been associated with poor response to neuroleptics, enlarged ventricles, cognitive impairment, and poor outcome in schizophrenia. These associations appear, however, to be dependent on the phase of study, suggesting that acute-phase (phasic) negative symptoms may be pathophysiologically distinct from enduring negative symptoms that persist through the residual phase. To compare correlates of enduring and phasic negative symptoms, we studied 60 drug-free schizophrenic patients (DSM-III-R and SADS/RDC) at baseline, 4 weeks after neuroleptic treatment, and assessed the 1 year outcome. We rated positive and negative symptoms at baseline and 4 weeks after treatment. At baseline, premorbid function, neuropsychological function, ventricle-brain ratio (VBR) and symptom response to an anticholinergic agent were assessed, and a two-night sleep EEG and 1mg dexamethasone suppression test (DST) were conducted. Phasic negative symptoms were defined as the change in negative symptoms (baseline to 4 weeks) and enduring negative symptoms as severity of negative symptoms at 4 weeks. Patients had varying proportions of phasic and enduring symptoms; the two did not define distinct subgroups. Phasic negative symptoms were significantly correlated with global treatment response, positive symptom treatment response, response to anticholinergic agent, baseline post-dexamethasone cortisol, and shortened REM latency. Enduring negative symptoms were significantly correlated with residual positive symptoms and global psychopathology, VBR, poor performance on neuropsychological testing, decreased slow-wave sleep, poor premorbid function, and poor 1 year outcome. These data suggest that phasic negative symptoms and enduring negative symptoms may be caused by different pathophysiological mechanisms.

Determination of low-molecular-weight carboxylic acids in the ambient air and vehicle emissions: a review

This review surveys analysis of airborne and vehicle emitted low-molecular-weight carboxylic acids. Attention is paid to providing a comprehensive coverage of collection techniques, sample handling, storage, extraction methods followed by a discussion of recent developments in carboxylic acid analysis using chromatographic (gas and ion chromatography) and electrophoretic (capillary electrophoresis) techniques. The occurrence and sources of carboxylic acids in the ambient air are also summarized.

Effect of a curfew law on juvenile trauma

OBJECTIVE

As a method of crime reduction among teenagers, several cities, counties, and states across the country have enacted, or attempted to enact, curfew laws. A curfew law was successfully implemented in Dade County, Florida, in January of 1996. Although its efficacy for crime reduction has been questioned, its benefit for trauma prevention may be real.

METHODS

Trauma registry data was collected retrospectively and prospectively from Dade County's Level I trauma center for all trauma victims 5 to 16 years of age. The time period spanned the 2 years before the institution of the curfew law (January 1, 1996) and the 2 years after. Total adult and pediatric trauma volumes during the 4-year period were used as comparisons, as well as juvenile traumas occurring during noncurfew hours.

RESULTS

Total trauma volume did not change significantly across the 4-year period, nor did the volume among the curfew age group during noncurfew hours. The predominant mechanisms of injury during curfew hours were motor vehicle crashes and gunshots. Neither the patterns of mechanisms nor ages changed significantly during the precurfew and postcurfew eras. However, the volume of cases seen at the trauma center among the curfew age group was significantly lower with the curfew law in effect (mean, 7.0/month) than before it was in effect (mean, 9.5/month, p = 0.043).

CONCLUSION

Although the overall trauma admissions and juvenile trauma admissions during the noncurfew hours remained relatively stable, juvenile trauma admissions during curfew hours dropped significantly in the 2 years after enforcement of the curfew law compared with the 2 years before the curfew law. This finding suggests that attempts to prevent late-night nonproductive street presence among teens can decrease the incidence of trauma occurrences.

Sarcoidosis in a patient with AIDS: a manifestation of immune restoration syndrome

Sarcoidosis has been rarely reported in the presence of HIV infection. Helper T-lymphocyte depletion may attenuate granuloma formation. We present a patient who developed active sarcoidosis after being started on highly active antiretroviral therapy (HAART), which increased his CD4 count and decreased his viral load. There have been reports of exaggerated responses to mycobacteria and viruses with the restoration of T-cell function after HAART in HIV-infected patients. We propose that active sarcoidosis seen in this patient is also a manifestation of this newly observed "immune restoration disease."

Successful PBSC mobilization with high-dose G-CSF for patients failing a first round of mobilization

PBSC are the preferred source of stem cells for autologous transplantation. However, regardless of the mobilization procedure used, 10%-20% of patients fail to collect an adequate number to ensure prompt engraftment. There is as yet no standard mobilization procedure for patients who fail a first mobilization attempt. Here, we describe a highly efficient strategy to obtain an adequate number of stem cells for patients who failed a first mobilization attempt. Seventy-four patients with various hematologic malignancies underwent initial mobilization with various regimens including hematopoietic growth factors with or without chemotherapy. In 72% of patients, > or =2 x 10(6) CD34+ stem cells/kg were collected in the initial mobilization attempt, and patients engrafted in a median of 10 days for neutrophils and 12 days for platelets. Eighteen patients failed to mobilize adequate numbers of stem cells, defined as the inability to collect 0.2 x 10(6) CD34+ stem cells/kg/day in the first 2-3 days. These patients had their apheresis halted. Patients were immediately given G-CSF (32 microg/kg/day) for 4 days as a second attempt at mobilization. Eighty-eight percent of these patients achieved the target of > or =2 x 10(6) CD34+ cells/kg, with a median duration of apheresis of 5 days (including the first and second mobilizations). The mean CD34+ cells/kg/day increased after administration of high-dose G-CSF from 0.16 after the first mobilization attempt to 0.61 (p = 0.0002) after the second mobilization. All patients engrafted in a median of 11 and 13 days for neutrophils and platelets, respectively. We conclude that patients whose apheresis yield is <0.4 x 10(6) CD34+ cells/kg after the first two apheresis collections can be successfully mobilized if high-dose G-CSF is administered immediately and continued until achieving > or =2 x 10(6) CD34+ stem cells/kg.

Characterization of Phytophthora infestans in Wisconsin from 1993 to 1995

Late blight of potato (Solanum tuberosum), caused by Phytophthora infestans, recently reappeared in Wisconsin and was a significant production problem in 1994. P. infestans isolates collected in Wisconsin from 1993 to 1995 were characterized for the following traits: mating type, sensitivity to metalaxyl, and allozyme genotype for Glucose-6-phosphate isomerase (Gpi). Characterization of these isolates revealed that a new, more aggressive population (A2 mating type, metalaxyl resistant, and Gpi genotype 100/111/122) is displacing the old population (A1 mating type, metalaxyl sensitive, and Gpi genotype 86/100) in Wisconsin.

Rewards and gratifications among family caregivers: towards a refined model of caring and coping

Supplemented by a case illustration, findings from a study in Wales are reported for the first time from the application of two new instruments for measuring rewards and stresses among family caregivers. The paper takes as its starting point a critique of models of caregiving which emphasize instrumental and pathological dimensions. Findings suggest that caregivers report the existence of pervasive rewards and gratifications, as well as stresses, as part of the caregiving experience, and that these stem from varying sources. The role of rewards and satisfactions in stress-coping models is briefly discussed, and implications for changed practice and policy thinking are reviewed.

The KSHV/HHV8-infected BCBL-1 lymphoma line causes tumors in SCID mice but fails to transmit virus to a human peripheral blood mononuclear cell graft

The body-cavity-based lymphoma cell line BCBL-1, which is infected with Kaposi's sarcoma-associated herpesvirus/human herpesvirus 8, was injected alone or with human peripheral blood mononuclear cells into SCID mice. Immunoblastic lymphomas developed at or near the site of injection. The lymphomas appeared to derive exclusively from the injected BCBL-1 cells and not from the injected human PBMC. The tumors elicited a marked murine angiogenic response, but known angiogenic cytokines were not detected in BCBL-1 cells. Transfer of BCBL-1 cells to SCID mice may represent an in vivo model for the study of KSHV/HHV8-stimulated angiogenesis.

IL-1 beta production by human polymorphonuclear leucocytes stimulated by anti-neutrophil cytoplasmic autoantibodies: relevance to systemic vasculitis

Neutrophils accumulate in the acute blood vessel lesions of patients with autoimmune systemic vasculitis. They have been shown previously to produce the cytokine IL-1 beta in response to stimulation with TNF. This study demonstrates that neutrophils can be stimulated by anti-neutrophil cytoplasmic antibodies (ANCA), which are present in patients with systemic vasculitis, to express mRNA and protein for IL-1 beta. Both human ANCA and MoAbs to a variety of autoantigens recognized by ANCA, including proteinase 3, myeloperoxidase, bactericidal/permeability increasing protein and elastase, are effective. This response can be inhibited by actinomycin and cycloheximide, suggesting a requirement for de novo protein synthesis. IL-1 beta production can be inhibited by pooled human intravenous immunoglobulins but not by FK506 or cyclosporin A. These data suggest that ANCA in patients with active vasculitis may stimulate neutrophils to produce cytokines. It is hypothesized that cytokine production from neutrophils that accumulate in significant numbers in vasculitic lesions contribute to and augment the local inflammatory response by the activation of vascular endothelial cells and infiltrating leucocytes.

Biological predictors of 1-year outcome in schizophrenia in males and females

This paper describes a prospective study designed to ascertain the predictive value of biological factors associated with schizophrenia in males and females. In a sample of 59 medication-free schizophrenic inpatients (41 males; 18 females), we assessed the correlation of four factors--rapid eye movement (REM) sleep latency, delta (slow-wave) sleep, dexamethasone suppression test (DST) cortisol levels, and ventricle-brain ratio (VBR)--with several dimensions of outcome at 1-year post-discharge. In the total sample, shorter REM latency was associated with poor outcome on all dimensions measured: rehospitalization, employment, social activity, symptomatology, and global functioning. However, none of the other biological factors were associated with any measure of outcome. The predictive value of REM latency appeared to be gender-specific; in general, the relationships between reduced REM latency and poor outcome were consistently noted in females, but were not significant in males. These results suggest that a common, possibly gender-related, pathophysiological mechanism might underlie both abnormal REM latency and poor outcome. The findings underscore the importance of considering gender differences in studies of schizophrenia.

Family stress and metabolic control in diabetes

The common clinical assumption that stress has a deleterious effect on metabolic control in insulin dependent diabetes mellitus (IDDM) has not been confirmed in children and adolescents. This cross sectional study of 43 children and adolescents with IDDM and their families examined the relations between family life stress, family social support, and metabolic control. High family life stress was found to be strongly correlated with HbA1c in the whole group (n = 43) and in children under 12 years (n = 27) when considered separately. Family social support was not found to be directly related to HbA1c, but was found to buffer the effects of family life stress. These findings support the hypotheses that family stress affects metabolic control in IDDM and that good social support buffers these deleterious effects.

Effects of dietary n-3 fatty acid supplementation in men with weight loss associated with the acquired immune deficiency syndrome: Relation to indices of cytokine production

Cytokines may be involved in weight loss and disturbances of metabolism associated with human immunodeficiency virus (HIV) infection. Dietary n-3 fatty acids reduce the production of interleukin-1 (IL-1) and tumor necrosis factor (TNF) by peripheral blood mononuclear cells (PBMC) in normal humans and prevent IL-1 and TNF anorexia in animals. Accordingly, we studied the nutritional and metabolic effects of a 10-week trial of dietary fish oil (MaxEPA 18 g/day) in men with weight loss due to acquired immune deficiency syndrome (AIDS). Twenty men were enrolled, and 16 completed the 10-week supplementation period. Prior weight loss was 13.7 +/- 1.8 kg(17.4 +/- 1.6% body weight, means +/- SE). Food intake, body composition, blood chemistries, serum cytokine concentrations, in vitro production of IL-1 and TNF by PBMC, and clinical course were followed. A subset of subjects (n=12) underwent stable isotope infusions to measure de novo hepatic lipogenesis (DNL), an in vivo metabolic index that is influenced by cytokine presence and has previously been found to be elevated in AIDS. An unsupplemented group of men with AIDS wasting (10.4 +/- 2.4 kg weight loss, 13.1 +/- 2.2% body weight) was monitored for 10 weeks as controls. Baseline food intake (2,395 +/- 177 kcal/day and 95.1 +/- 7.2 g protein/day), body weight, percent fat, and fat-free mass were unchanged over the 10-week supplementation period. Serum triglycerides were reduced in hypertriglyceridemic subjects, confirming compliance with fish oil supplementation and suggesting that their hypertriglyceridemia was at least in part due to overproduction. Serum TNF and IL-1 were undetectable before or after fish oil supplementation. Serum interferon alpha (IFN) was measurable but did not change. In vitro production of IL-1 and TNF by PBMC was markedly reduced both at baseline and after fish oil supplementation in this population, even in the presence of new AIDS complications, compared with normal controls. The metabolic measurement DNL fell and weight was gained (2.1 +/- 1.3 kg) in subjects who did not develop new AIDS-related complications, but further increases in DNL and further weight loss were observed in subjects who developed a new AIDS complication (p<0.05 for interaction between new complication and change in DNL). No changes in body weight, food intake, serum triglycerides, serum cytokines, or DNL were observed in the unsupplemented group. We conclude that fish oil is a weak anticytokine agent that is unable to overcome the metabolic and nutritional consequences of acute AIDS-related complications but may exert a clinical anticytokine effect in stable AIDS patients. Cytokine production by PBMC is not a useful or reliable marker of in vivo cytokine activity in AIDS patients with weight loss. In contrast, an integrative functional index that is sensitive to cytokine presence in tissues (hepatic DNL) correlated with clinical response. These findings are relevant to the design of future studies of more potent anticytokine agents, such as thalidomide.