Immediate and delayed leukocyte apoptosis in two models of peritonitis

Leukocyte apoptosis is an energy-dependent process that facilitates resolution of the cellular inflammatory response. Levels of apoptosis can be accelerated or inhibited after exposure to various stimuli. To compare apoptosis in transmigrated leukocytes, two models of peritonitis in mice were used that both cause leukocyte influx into the peritoneal cavity: (1) intraperitoneal thioglycollate administration producing a sterile peritonitis and (2) cecal ligation and puncture (CLP) producing a polymicrobial bacterial peritonitis. Samples of blood and peritoneal exudate cells (PEC) were collected at multiple time points after induction of peritonitis. Leukocytes were either fixed immediately to determine an immediate apoptosis level or cultured for 24 h to determine a delayed apoptosis level. Apoptosis was assessed using terminal uridine-triphosphate nick-end labeling (TUNEL) assay, flow cytometry, and confocal microscopy. Leukocyte influx into the peritoneal cavity was confirmed in both models. At all time points, and in both models, there was increased immediate apoptosis in PEC compared with unmanipulated controls and this increase was maximal in CLP after 18 h, although it appeared to remain at a stable level in the sterile peritonitis model by 3 h. There was also an increase in PEC delayed apoptosis at early time points in both models, again maximal at 18 h for CLP, with the levels being significantly higher than the thioglycollate model at 6 h and 18 h. The mice had a relative peripheral neutropenia at 6 h after CLP, but not post thioglycollate injection, and this persisted until 42 h. Lung and liver MPO levels were elevated in CLP but did not increase after thioglycollate. There was no increase in immediate peripheral leukocyte apoptosis in either model, but an increase in delayed peripheral leukocyte apoptosis was observed by 18 h in both models. Peripheral leukocyte CD1lb expression, which is a marker of activation, was also persistently elevated in the CLP model, but not in sterile peritonitis. In conclusion, CLP is a more potent stimulus for apoptosis of leukocytes than their migration to the site of inflammation alone, as occurs in the thioglycollate model. Blood leukocyte apoptosis also appears not to be dependent on CD11b expression, and therefore activation status.

The last fifty years of neonatal surgical management

Neonatal surgical mortality has steadily fallen over the last five decades. Improved survival does not appear to be related to the introduction of new operative procedures. Most of the basic procedures were developed by 1960. Eight developments appear to be responsible: (1) The growth of pediatric surgery resulted in widespread availability of neonatal surgeons and dissemination of knowledge about newborn surgical emergencies. (2) The parallel growth of pediatric anesthesia, beginning in 1946, provided specialized intraoperative management of the neonate. (3) Understanding neonatal physiology is the key to successful management; major advances occurred between 1950 and 1970. (4) New inventions revolutionized patient care; the transistor (1947) made it possible for medical devices to sense, amplify and control physiologic responses and opened the communication and computer age. (5) Neonatal mechanical ventilation had a prohibitive mortality and was seldom utilized; the development of CPAP and a continuous flow ventilator in the 1970s allowed safe ventilatory support. (6) Total parenteral nutrition (1968) prevented starvation that frequently affected infants with major anomalies. (7) The effective treatment of infection began with the clinical use of penicillin (1941); antibiotics have reduced mortality but infants suffering from the septic syndrome have a prohibitive mortality; cytokine, proinflammatory agent research, and the development of anti-inflammatory and blocking agents in the 1980s have not affected mortality. (8) The establishment of newborn intensive care units (1960) provided an environment, equipment, and staff for effective physiologic management.

Prenatal exposure to the dopamine agonist SKF-38393 disrupts the timing of the initial response of the suprachiasmatic nucleus to light

The abuse of social drugs such as cocaine during pregnancy represents enormous risks to the offspring. Recent studies showed that drugs administered to the pregnant rat can activate cell populations in the fetal brain, possibly altering the timing of key neuronal developmental events. The current study examined the ontogeny of light-responsiveness of the neonatal rat suprachiasmatic nucleus using c-FOS protein in SCN nuclei as a marker. The effect of acute administration of the dopamine D1 agonist, SKF-38393, on the development of light responsiveness was also examined. Pregnant dams received either SKF-38393 (10 mg/kg) or vehicle 7 h after dawn on gestational day 20. Litters were then assigned to one of seven experimental time points from 4 h after subjective dark onset on the day of birth (P0-CT16) at 4-h intervals until CT16 on the day after birth (P1-CT16). Half of the pups in each litter were exposed to a 200 lux/2 h light pulse and the other half remained in darkness. Three time points (P1-CT0, P1-CT8 and P1-CT16) were used to examine the prenatal drug effects on light-responsiveness. Light exposure at the time of subjective lights on, the day after birth (P1-CT0), resulted in a significant increase in c-FOS-positive cells. The number of positive cells recorded in the SCN after a light pulse at P1-CT0 and P1-CT8 was significantly less in SKF-38393 pretreated pups compared to vehicle treated animals. The exposure to dopaminergic stimulation during gestation may have altered the timing of development of afferent connections to the fetal SCN, resulting in alteration of the initial response of the circadian timing system to light.

Effect of stimulation of endogenous melatonin secretion during constant light exposure on 6-sulphatoxymelatonin rhythmicity in rats

When light is presented unexpectedly at night to rats, melatonin production and secretion is acutely inhibited and the time of onset of production on the subsequent night is altered. In a series of experiments, we examined the effects of 6-12 hr light (200 lux) at night on melatonin metabolite excretion (6-sulphatoxymelatonin, aMT.6S). During the light exposure, we administered isoproterenol to stimulate endogenous production of melatonin by the pineal gland to determine if replacement of melatonin would block any phase shifting effects of the light. Exposure to 6 hr of light either during the first or second half of the night suppressed aMT.6S excretion during the light treatment and delayed the onset of melatonin secretion by 3.7 +/- 0.6 and 2.5 +/- 0.6 hr, respectively, compared to a change of 0.5 +/- 0.1 hr in animals maintained in darkness. Twelve hours light exposure (i.e. one night of continuous light) suppressed aMT.6S excretion completely and resulted in a delay in the onset the next night of 2.1 +/- 0.7 hr. When propranolol (10 mg/kg) was administered at 2-hr intervals during darkness, aMT.6S excretion was suppressed throughout the night, but on the subsequent release into constant darkness the onset of excretion was not delayed (0.6 +/- 0.1 hr delay). Administration of isoproterenol (10 mg/kg) to animals in constant light, at the time of expected lights off (CT12), and 5 hr later (CT17) resulted in an increase in melatonin production and aMT.6S excretion that was similar in duration and amount to the control night. The stimulation of endogenous melatonin production failed to block the phase shifting effects of the light exposure and, in fact, appeared to potentiate the delay at least on the first night (4.2 +/- 0.9 hr). The timing of the release into constant darkness following the light treatment had an unexpected effect on melatonin production on the cycle after treatment. Thus, animals exposed to 12 hr light and released into darkness at the normal time of lights off as above had a delay of about 2 hr and excreted 71 +/- 18% of the aMT.6S excreted on a control night. Animals released into darkness at the expected time of lights on failed to excrete more than 20 pmol/hr(i.e. no onset of excretion could be determined) at any time on the first subjective night after light treatment, which was no different from the excretion during the light treatment. On the next subjective night, the onset was delayed as expected and the amount of aMT.6S produced was restored. Treatment with isoproterenol at CT12 and CT17 failed to affect either the amount of aMT.6S excreted on the first subjective night after light treatment or the phase delay on the second night after treatment. The failure to produce melatonin on the first subjective night after 12 hr light exposure and release into darkness at CTO was not due to failure at the level of the pineal gland since injection ofisoproterenol at CT12 and CT17 on the first subjective night after light restored the normal amount of melatonin production. These results suggest that the absence of melatonin during light stimulation at night is not responsible for the phase delay in melatonin production and excretion on subsequent nights. The basis of the failure of the rats to commence melatonin production following 12 hr extended light exposure followed immediately by continuous darkness is not known.

Controlled-release melatonin implants delay puberty in rats without altering melatonin rhythmicity

There is increasing evidence that continuous availability of melatonin via implants can produce the same physiological changes in animals as timed administration of the hormone. The mechanisms underlying this apparent contradiction are not known. In an attempt to gain further understanding of the way continuous melatonin administration affects reproductive activity, the effects of melatonin implants on gonadal development and melatonin production were investigated in rats treated neonatally with testosterone. Five-day-old male rats maintained on a 12L:12D photoperiod were injected with 1 mg testosterone propionate to induce photo-responsiveness and implanted at 21 days of age with novel melatonin implants designed to raise the daytime blood melatonin concentration into the nighttime range, i.e., from less than 60 pM in the controls during the day to 380 +/- 33 pM in the implanted rats. Following 21 days treatment, seminal vesicle and ventral prostate weights of implanted rats were significantly less than the controls (27.0 +/- 1.9 vs. 18.5 +/- 1.5 mg/ 100 g BW (P = 0.003) and 33.8 +/- 2.1 vs. 26.7 +/- 2.2 mg/100 g BW (P = 0.02), respectively). To determine the effect of the implants upon melatonin production, urine was collected at hourly intervals during the last four days of the experiment and the hourly 6-sulphatoxymelatonin (aMT.6S) excretion rate was determined. Rats bearing melatonin implants maintained a rhythm of aMT.6S excretion in 12L:12D, which was indistinguishable from that in the control animals except for a raised daytime excretion of the metabolite. Following one cycle of urinary aMT.6S measurements in the light/dark cycle, the animals were released into constant darkness, with the implants still in place or after their removal four hours before darkness to evaluate the characteristics of the melatonin rhythm in the absence of masking effects of the light/dark cycle. The melatonin rhythm persisted in both control and implanted rats and no differences in the onset, offset, or amplitude could be determined. The results of this study indicate that, like many other mammals, for laboratory rats controlled continuous release of melatonin can mimic the effects of short daylength or timed melatonin administration. Despite the reproductive consequences of continuous melatonin delivery, the timing of endogenous melatonin production is unaffected.

Serotonin agonists mimic the phase shifting effects of light on the melatonin rhythm in rats

The effect of serotonin agonists on the rhythmic excretion of the melatonin metabolite 6-sulphatoxymelatonin was examined in rats. The animals were maintained in 12L:12D and administered saline, quipazine (10 mg/kg), (+/-)-2-propylamino-8-hydroxy-1,2,3,4-tetrahydronaphthalene hydrobromide (8-OH-DPAT, 5 mg/kg) or buspirone (10 mg/kg), 4 h after dark (ZT16). All three drugs caused an acute, transient suppression of 6-sulphatoxymelatonin excretion and a significant delay (P < 0.01) in the onset of the nocturnal rise on the following night of 2.1 +/- 0.6, 1.4 +/- 0.7 and 1.5 +/- 0.3 h respectively while saline administration had no effect (0.4 +/- 0.2 h delay, P > 0.01). To examine the effects of the time of day of agonist administration, groups of rats were treated with quipazine (10 mg/kg) or 8-OH-DPAT (5 mg/kg) 18, 24 or 30 h after the initiation of continuous darkness (CT6, CT12 or CT18) and monitored for a further two nights. Quipazine but not 8-OH-DPAT injection at CT6 resulted in a small but significant delay in the onset of 6-sulphatoxymelatonin excretion on the following night (1.0 +/- 0.2 h and 0.3 +/- 0.2 h) while treatment with both agonists at CT12 failed to affect the onset of excretion (0.8 +/- 0.2 and 0.1 +/- 0.2 h). When quipazine (10 mg/kg) was administered at CT18, 6-sulphatoxymelatonin excretion was acutely suppressed for the rest of the night and there was a large significant delay in the onset of 6-sulphatoxymelatonin excretion (1.2 +/- 0.2 h) while a smaller delay was observed following 8-OH-DPAT administration (0.8 +/- 0.2 h). The acute suppression of 6-sulphatoxymelatonin excretion and subsequent phase delay following quipazine treatment at CT18 was also evident at doses of 1 mg/kg (1.6 +/- 0.4 h) and 3 mg/kg (1.5 +/- 0.6 h). These results show that peripheral administration of serotonin agonists active at 5HT1a/5HT7 receptors mimic the dual effects of light on melatonin production in the rat and raise the possibility that serotonin pathways are more important in mediating the effects of retinally perceived light in the rat than previously believed.

Cardinal clinical signs in the differentiation of heart murmurs in children

OBJECTIVE

To determine the diagnostic accuracy of clinical assessment of heart murmurs in children and specific clinical features that are predictive of cardiac disease.

DESIGN

Concurrent case series with pretest-posttest assessment.

SETTING

Pediatric cardiology outpatient clinic.

PARTICIPANTS

Five full-time academic pediatric cardiologists.

MEASURES

For each of 222 consecutive patients who were seen for first-time evaluation of a heart murmur, the clinical findings and diagnostic impressions were recorded after clinical assessment. The results of electrocardiograms and echocardiograms were then reviewed, and changes in diagnostic impressions were recorded and compared with the original impressions.

RESULTS

The prevalence of cardiac disease was 33%. Clinical assessment differentiated those patients with pathologic murmurs with a sensitivity of 92%, specificity of 94%, positive predictive value of 88%, and negative predictive value of 96%. If diagnostic uncertainty was considered an indication for echocardiography, then sensitivity and specificity increased to 97% and 98%, respectively. Missed disease included only trivial or minor lesions. Clinical features that were independently predictive of the presence of disease included murmurs that were pansystolic (odds ratio [OR], 54.0), grade 3 or more in intensity (OR, 4.84), heard best at the left upper sternal border (OR, 4.24) and harsh in quality (OR, 2.37), and the presence of an abnormal second heart sound (OR, 4.09) and an early or midsystolic click (OR, 8.35).

CONCLUSIONS

Clinical assessment by a pediatric cardiologist is sufficient to distinguish pathologic from innocent heart murmurs. A genetic approach by using specific clinical features that are independently associated with disease may have some practical utility to noncardiologists.

Effect of NMDA receptor blockade on melatonin and activity rhythm responses to a light pulse in rats

The possible role of the excitatory amino acids as mediators of the acute suppression and subsequent delay by light of pineal melatonin production was studied in rats using the NMDA receptor antagonist MK-801. Saline or MK-801 in doses up to 3 mg/kg (IP), was administered 15 min before a 15-min light pulse (200 lx), 4 h after dark onset, and the excretion of 6-sulphatoxymelatonin (aMT.6S) determined. Under these conditions saline injected/light exposed animals exhibited an acute, total but transient suppression of urinary aMT.6S excretion and a delay in the onset of aMT.6S the following night of 1.5 +/- 0.2 h. MK-801 failed to block either the acute or phase delaying effect of light (onset delayed by 2.2 +/- 0.4 h). Pretreatment with MK-801 (3 mg/kg) failed to block the effects of shorter, less intense light pulses 15 min before the pulse (e.g., 1 min/2 lx; onset delayed by 2.0 +/- 0.4 h following saline, 1.5 +/- 0.1 h following MK-801) or 60 min before a short duration low intensity pulse. In other experiments MK-801 (1 and 3 mg/kg) failed to affect aMT.6S excretion when injected in the dark at the time of lights out or 4 h after dark onset. NMDA (10 and 30 mg/kg) injection at the time of lights out or 4 h after darkness did not mimic the effects of a light pulse by decreasing aMT.6S excretion or causing a delay in the onset of excretion the following night. Finally MK-801 (3 mg/kg) injected 4 h after dark failed to block the phase delaying effects of a 15 min light pulse (200 lx) on running activity in rats. These results do not support the hypothesis that excitatory amino acids in the retino-hypothalamic tract acting on the NMDA receptor subtype and terminating in the suprachiasmatic nucleus mediate the photic influences upon rat pineal melatonin and activity rhythms.

An evaluation of parental concerns and misperceptions about heart murmurs

This study sought to determine the extent of anxiety and misperceptions about heart murmurs for consenting parents of 182 children referred for first-time pediatric cardiology assessment (including echocardiography) of a heart murmur. From questionnaires completed before assessment, 22% of parents indicated that they were extremely concerned, and only 16% could define a heart murmur as a sound made by the heart. From 1-month follow-up questionnaires obtained from parents of children without heart disease at assessment, 10% continued to believe that their child had a heart problem. Cardiology assessment may not provide complete reassurance to all families and additional interventions may be necessary.

Characterization of the chicken brain melatonin-binding protein using iodinated and tritiated ligands

The melatonin-binding protein in chicken brain membranes was characterized using both [125I]-2-iodomelatonin and [3H]-melatonin as radioligands. Saturation studies conducted at 25 degrees C revealed a single class of binding site with dissociation constants of 24 +/- 4.8 pM (n = 7) and 125 +/- 21 pM (n = 6) for the iodinated and tritiated ligands, respectively. Calculation of the affinity constant using data from kinetic experiments gave values of 2.2 +/- 0.4 pM and 135 +/- 15 pM for the iodinated and tritiated ligands, respectively. Competition studies showed that the rank order of inhibition of binding by melatonin analogues was similar for both radioligands (2-iodomelatonin > melatonin > 2,3-dihydromelatonin > N-acetyl-5-methoxykynurenamine > N-acetylserotonin > 5-methoxytryptamine). The calculation of Ki, which depends upon the affinity constant, was 22 +/- 4.9 pM and 129 +/- 21 pM for 2-iodomelatonin and melatonin, respectively, when the affinity constant derived from the [125I]-2-iodomelatonin saturation experiments was used, but 4.9 +/- 1.5 pM and 33 +/- 5.5 pM when the kinetically derived constant was used. When [3H]-melatonin was used, the Ki for melatonin was 72 +/- 8 pM and 20 +/- 4.6 pM for 2-iodomelatonin and melatonin. Binding of [125I]-2-iodomelatonin to the membranes was partially reversible at 25 degrees C in contrast to the complete reversibility of [3H]-melatonin. Examination of the effects of temperature on binding indicated that at 37 degrees C both association and dissociation of both ligands were accelerated. Closer examination showed that at 37 degrees C there was a loss of approximately 40% of the [125I]-2-iodomelatonin binding sites and little influence upon the affinity of binding with time. By contrast, when [3H]-melatonin was used, the affinity decreased fourfold, with only a slight change in the number of sites. If membranes were incubated at 37 degrees C and then switched 25 degrees C, binding increased, emphasizing the fact that the binding sites were not destroyed. Whereas there appears to be little doubt that 2-iodomelatonin is a biologically active melatonin agonist, the binding of the radioactive form of this agonist to the putative melatonin receptor binding site is quite different from that of the endogenous ligand. This may have serious consequences in studies where receptor content is determined following physiological or pharmacological interventions.

Impact of light pulses on 6-sulphatoxymelatonin rhythms in rats

The acute and residual entraining effects of a 15 min pulse of light on rat pineal function in individual animals were investigated using the excretion rate of the melatonin metabolite, 6-sulphatoxymelatonin, as an index of melatonin production. In animals maintained in a 12-hr L:12-hr D photoperiod (lights off 1800), 15 min light exposure at 2000 had no significant effect on the metabolite rhythm. Light pulses at 2200 (i.e., after the onset of excretion) decreased the melatonin metabolite excretion rate for 3 hr, after which the excretion rate increased to normal. In contrast, pulses at 2400 and 0200 suppressed 6-sulphatoxymelatonin for the rest of the night such that total excretion was 58 +/- 8% and 66 +/- 6% of the amount excreted on the night before the pulse. A light pulse at 0400 had no significant effect on the 6-sulphatoxymelatonin excretion when compared with the first night collection. When the 6-sulphatoxymelatonin rhythm was assessed on the night following light pulses at 2000 and 0400, the onset of metabolite excretion was unaffected (0.2 +/- 0.75-hr advance and 0.75 +/- 0.15-hr delay, respectively). In contrast, pulses at 2200, 2400, and 0200 resulted in significant delays in the onset of 2.4 +/- 0.2-hr, 1.5 +/- 0.1-hr, and 2.1 +/- 0.3-hr, respectively (P < 0.05). The offset of metabolite excretion was not significantly affected by a prior light pulse, except in animals receiving light treatment at 0400 when the offset was advanced by 1.5 +/- 0.3 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

Occurrence of presyncope in subjects without ventricular innervation

1. To determine whether activation of the left ventricular C-fibre mechanoreceptors initiates the vasodepressor reflex that often causes syncope, we exposed six orthotopic cardiac transplant patients and six matched, healthy control subjects to progressively increasing lower body negative pressure until the onset of vasodepressor responses. 2. There was no significant difference (P = 0.78) between the central hypovolaemia tolerances of the cardiac transplant and the control groups. 3. The decrease in systolic blood pressure before the onset of vasodepressor reflexes was greater in the cardiac transplant group. The cardiac transplant group did not maintain diastolic blood pressure during central hypovolaemia. From baseline to the onset of vasodepression, there were no differences in leg circumference, forearm blood flow and forearm vascular resistance responses between the two groups. 4. We conclude that the left ventricular mechanoreceptors may not be the primary afferent trigger for syncope.

Lung function and pulmonary regurgitation limit exercise capacity in postoperative tetralogy of Fallot

Fifty-five patients with repair of tetralogy of Fallot were evaluated with treadmill exercise, pulmonary function testing and rest two-dimensional and Doppler echocardiography to determine the relation among cardiopulmonary function, exercise capacity and ventricular arrhythmias. The mean age at repair was 8.1 +/- 2.1 years; age at the time of study ranged from 15 to 37 years (mean follow-up time after repair 18 +/- 5 years). Exercise duration was 92 +/- 17% of predicted. Maximal heart rate was 94 +/- 7% of predicted. No exercise test was stopped because of an arrhythmia. Thirty patients had oxygen consumption and ventilation measured during their final minute of exercise. Peak oxygen consumption was 31 +/- 8 ml/kg per min (86 +/- 18% of predicted). Twenty-five patients (45%) had low vital capacity at rest (less than 80% of predicted). Pulmonary regurgitation was identified in 42 (75%) of the patients and judged to be moderate in 10 (18%). Mild tricuspid valve regurgitation was identified in 64%. Doppler estimated right ventricular outflow gradient was greater than 15 mm Hg in 15% of the patients (mean gradient 24 mm Hg [range 16 to 56]). Age at repair, duration of follow-up and type of repair did not correlate with echocardiographic variables, ventilatory data, exercise performance or arrhythmias. Moderate pulmonary regurgitation was associated with increased right ventricular diastolic area and both were inversely related to exercise duration and vital capacity. Decreased breathing reserve during maximal exercise was associated with moderate pulmonary regurgitation and decreased vital capacity. The results indicate that exercise capacity in these patients is in general good; however, right ventricular volume loading and ventilatory dysfunction may produce exercise limitation.

HIV-associated myocarditis. Pathology and immunopathology

Autopsy studies of AIDS (acquired immune deficiency syndrome) patients showed a high incidence of myocarditis. To attain a better understanding of the pathogenesis, the pathology and immunopathology of nine endomyocardial biopsies with active myocarditis from 18 human immunodeficiency virus (HIV)-positive patients were systematically characterized. These were compared with 17 biopsies with active myocarditis from patients without AIDS risk factors. In both groups, the myocarditis consisted of either multifocal or interstitial infiltrates of small lymphocytes and isolated myocyte necrosis. The lymphocytes consisted of T cells (CD2+, CD3+) and cells not identified by the usual markers. B cells, monocytes, CD4+ cells, and natural killer (NK) cells were only rarely observed. All of the HIV-positive patients but only 7 of 17 non-HIV patients had CD8+ lymphocytes in the infiltrates (P less than 0.01). The arteriolar endothelium demonstrated induced class I (HLA-A, B, C) and II (HLA-DR) antigens in both groups. In situ hybridization for HIV-1 failed to identify the virus in the specimens. The immunopathology is consistent with a cell-mediated injury to the myocytes in HIV-positive patients and is similar to a subgroup of myocarditis in the non-HIV group.

Meningism in a ten-month-old infant during OKT3 therapy

Organ transplantation has become widely applied as a therapy of end-stage organ dysfunction and is finding increasing application in the pediatric population. This has become possible largely through the use of improved immunosuppressive agents, such as OKT3. Aseptic meningitis associated with OKT3 has been previously reported, with a frequency rate of 3% to 14%, in adult renal allograft recipients. Aseptic meningitis after OKT3 therapy has not been reported in children. Meningitis, however, is a frequent infection encountered in young children, and the development of meningeal irritation during therapy with OKT3 may present a diagnostic dilemma. We describe aseptic meningitis in a 10-month-old infant after treatment of cardiac allograft rejection with OKT3.

Long-term results of total repair of tetralogy of Fallot in childhood

Between 1958 and 1977, 170 children aged 10 years or less underwent total repair of tetralogy of Fallot at The Johns Hopkins Hospital. Follow-up data were obtained on 128 (90%) of the 143 who survived the operation at 10 to 28 years postoperatively (mean follow-up, 18 years). All patients completed an extensive questionnaire, and 59 returned for a thorough evaluation consisting of a history and physical examination, electrocardiogram, 24-hour Holter monitoring, exercise stress testing, pulmonary function testing, and two-dimensional and Doppler echocardiography. Late survival was excellent with only two of four known late deaths due to cardiac-related causes and with all 59 patients in New York Heart Association class I or II. None had cyanosis or clubbing. Normal sinus rhythm was present in 90%. One patient had complete heart block, and 75% had right bundle-branch block on the electrocardiogram. Right ventricular function was normal by echocardiography in 78%. Residual mild to moderate pulmonary stenosis was noted by Doppler study in 8 patients. Pulmonary regurgitation was present in 78%, but in only 11 patients was it graded as moderate and in none was it severe. Stress testing documented the excellent functional status of most patients, with 92% of predicted exercise time and 94% of maximum heart rate being attained. In the few who had impaired cardiac performance, this correlated best with moderate pulmonary regurgitation. Although the overall late functional status of patients undergoing repair in the first decade of life was very good, these patients need continued follow-up to assess the severity of pulmonary regurgitation and the need of possible intervention.

Automated blood pressure measurements during exercise

One of the critical parameters measured during exercise is blood pressure. However, the accurate measurement of systolic and diastolic blood pressure during exercise is difficult with auscultation and impractical with direct arterial techniques. The purpose of this study was to compare an automated system (Colin, Inc. STBP-680) with auscultation in humans during rest and exercise and to compare the automated system with direct arterial blood pressure measurement in a canine model during pharmacological challenges that resulted in a wide range of blood pressure values. Compared with direct arterial blood pressure taken in the canine model, the STBP-680 gave good estimates of diastolic blood pressure and adequately monitored relative changes in systolic blood pressure, diastolic blood pressure, and mean arterial pressure (mean arterial pressures in all instances were calculated as one-third systolic plus two-thirds diastolic blood pressures). Compared with auscultation methods in humans, the STBP-680 gave similar estimates of resting diastolic blood pressure and monitored relative changes in resting systolic blood pressures, diastolic blood pressures, and mean arterial pressures. During both treadmill and cycle ergometer exercise in humans, the STBP-680 monitored changes in systolic blood pressure, phase IV diastolic blood pressure, and mean arterial pressure. Further, the STBP-680 estimated exactly and noted relative changes in heart rate in every test. However, during exercise, quantitative estimations of systolic blood pressure by the STBP-680 were higher than those found using auscultation. Where exact, quantitative measures of blood pressure are needed, direct arterial measurement continues to be the most accurate method. However, where indirect methods can be used, the STBP-680 may provide a suitable alternative that reduces many of the technical concerns of auscultation in young, healthy individuals.

Long-term valvular function after total repair of tetralogy of Fallot. Relation to ventricular arrhythmias

Patients with total repair of tetralogy of Fallot may have residual valvular dysfunction, the long-term effect of which is poorly defined. We prospectively studied 59 patients for 18 +/- 5 (mean +/- SD) years postoperatively by Doppler echocardiography and by 24-hour electrocardiographic monitoring. Right ventricular outflow gradients were estimated from the peak continuous-wave Doppler pulmonary artery velocity. The severity of valvular regurgitation was determined by mapping the proximal chamber by pulsed Doppler methods. Right ventricular diastolic cavity area was measured by planimetry of the apical image. The right ventricular outflow tract gradient had a mean value of 9.4 +/- 9.0 mm Hg (range, 0-58 mm Hg; median, 6.6 mm Hg). Pulmonary regurgitation was present in 78% of patients, with 59% of patients graded as mild and 19% as moderate. Tricuspid regurgitation was found in 65% of patients, with 56% of patients graded as mild, 7% as moderate, and 2% as severe. The severity of pulmonary regurgitation correlated with right ventricular cavity area (p less than 0.05). The severity of tricuspid regurgitation was not related to pulmonary stenosis or to the severity of pulmonary regurgitation. Aortic regurgitation is unusual (n = 11) and correlates with aortic root size. The frequency and type of ventricular arrhythmia were not related to the severity of pulmonary stenosis; however, ventricular bigeminy and couplets were related to the severity of pulmonary regurgitation (p less than 0.025). The majority of patients with total repair of tetralogy of Fallot have remarkably good long-term valvular function. For the minority with moderate or severe valvular dysfunction, pulmonary regurgitation is the best marker for ventricular arrhythmias.