New Therapeutic Avenues with Hybrid Pediatric Cardiac Surgery

Abstract Background: Minimally invasive strategies can be expanded by combining standard surgical and interventional techniques. Methods: A longitudinal prospective study was conducted of all pediatric patients who have undergone hybrid cardiac surgery at the University of Chicago Children's Hospital. Hybrid cardiac surgery was defined as combined catheter-based and surgical interventions in either one surgical setting or planned sequential surgical settings within a 24-hour period. Results: Between June 2000 and June 2003, 24 patients were treated with hybrid approaches. Sixteen patients with muscular ventricular septal defects (VSDs)with a mean age of 4 months (range, 2 weeks to 4 years) underwent either sequential Amplatzer device closure in the catheterization laboratory followed by surgical completion (group 1A [n = 9]: right ventricular (RV)outflow tract enlargement, 6 patients; closure of other VSDs, 5 patients; tricuspid valvuloplasty, 3 patients; bidirectional Glenn shunt, 1 patient; Maze procedure, 1 patient; and retrieval of embolized device, 1 patient) or, more recently, a 1-stage intraoperative off-pump device closure (group 1B;n =7)with the subsequent repair of concomitant heart lesions in 5 patients (double-outlet RV, 2 patients; arch hypoplasia/coarctation of the aorta, 2 patients; and pulmonary artery (PA) debanding, 1 patient). Cardioplegic arrest was either avoided or shortened in the muscular VSD patients. Eight patients with branch PA stenoses (group 2)underwent intraoperative PA stenting or stent balloon dilation along with RV outflow procedure (5 patients)or Fontan completion (3 patients with Maze procedure, mitral valvuloplasty, or Damus-Kaye-Stansel procedure in 1 patient each). All patients survived hospitalization. Complications from the hybrid approach in group 1A patients included tricuspid regurgitation in 2 patients, RV disk malposition in 1 patient, embolization of a VSD device into the aorta in 1 patient, and a residual VSD in 1 patient. No complications from the hybrid approach occurred in group 1B patients, and PA rupture from stent overinflation and ventricular dysfunction occurred in 1 patient each in group 2. During a mean follow-up period of 18 months (range, 2-36 months), 2 group 1A patients died suddenly several months after discharge. All of the other patients are doing well. Conclusions: Hybrid pediatric cardiac surgery performed in tandem by surgeons and cardiologists is a safe and effective means of reducing or eliminating cardiopulmonary bypass. Patients with muscular VSDs who are small, have poor vascular access, or have concomitant cardiac lesions are currently treated in one setting with the perventricular approach.     

Prognostic value of SSEP in early aneurysm surgery after SAH in poor-grade patients

We evaluate the prognostic value of somatosensory evoked potentials (SSEP) in poor-grade patients after early surgery for aneurysmal subarachnoid hemorrhage compared to the Hunt and Hess (H&H) and WFNS scales. Ninety patients with angiographically proven aneurysms graded H&H IV or V were evaluated retrospectively. The aneurysms of 72 patients were clipped. In 53 out of 72 patients 147 SSEP examinations were recorded. The SSEP were classified according to the central conduction time (CCT) and the number of cortical potentials. Outcome was determined according to the Glasgow Outcome Scale. To evaluate the predictability of the SSEP to clinical grading scales receiver operating characteristic (ROC) analysis was done. The H&H scale did not demonstrate statistically significant predictability for poor-grade patients. The WFNS scale predicted the outcome for only one group (survival/death) (p = 0.035). Predictability of outcome by the SSEP was statistically confirmed. Normal CCT indicated a potential for a good recovery, but not consistently so. Bilaterally enhanced CCT was predictive of a poor outcome. Bilateral lack of cortical responses was always related to fatal outcome. ROC analysis confirmed that SSEP are superior to clinical grading scales in determining prognosis in poor-grade patients. In doubt, whether early aneurysm surgery or conservative treatment in a poor-grade patient should be done, SSEP will be helpful.     

Reproductive skew in the polygynandrous acorn woodpecker

Reproductive skew models, which focus on the degree to which reproduction is shared equally (low skew) or monopolized by a single individual (high skew) within groups, have been heralded as providing a general unifying framework for understanding the factors determining social evolution. Here, we test the ability of optimal skew, or "transactional," models, which predict the level of skew necessary to promote stable associations of dominants and subordinates, rather than independent breeding, to predict reproductive partitioning in the acorn woodpecker (Melanerpes formicivorus). This species provides a key test case because only a few vertebrates exhibit polygynandry (multiple breeders of both sexes within a group). Contrary to the predictions of the models, joint-nesting females share reproduction more equitably than expected, apparently because egg destruction and the inability of females to defend their eggs from cobreeders eliminate any possibility for one female to control reproduction. For males, however, reproductive skew is high, with the most successful male siring over three times as many young as the next most successful male. Although this result is consistent with optimal skew models, other aspects of male behavior are not; in particular, the reproductively most successful male frequently switches between nests produced by the same set of cobreeders, and we were unable to detect any phenotypic correlate of success. These results are consistent with an alternative null model in which cobreeder males have equal chance of paternity, but paternity of offspring within broods is nonindependent as a consequence of female, rather than male, control.     

Religion,religiosity and spirituality in the biopsychosocial model of health and ageing

Religiosity/spirituality and the tendency to use these in coping are common in older adults. We review evidence that these are positively associated with mental and physical health in older adults, as well as evidence that members of different religious groups differ in levels of health. Studies on mental health include those that examine well-being and depression. Physical health outcomes include mortality, cancer, stroke, and physical functioning. We discuss the issue of causality and possible mediators of effects of religiosity/spirituality on health outcomes, paying special attention to possible psychological mediators. Last, we discuss possible differences in these associations between members of various cultural and religious groups, and caution that there may be theological problems with the use of religion to promoting health. Adam B. Cohen, Ph.D., is a social and cultural psychologist with his primary interest in the ways different religious communities shape their members’ views about religiosity, morality, forgiveness, and health. Dr. Cohen is currently an assistant specialist at the Institute for Personality and Social Research at the University of California, Berkeley. Harold G. Koenig, M.D., M.H.Sc., is board certified in geriatric psychiatry and geriatric medicine, and is on the faculty at Duke University as an Associate Professor of Psychiatry and an Associate Professor of Medicine. Dr. Koenig is founder and director of the Center for the Study of Religion/Spirituality and Health at Duke. He has published extensively in the fields of mental health, geriatrics, and religion, with more than 200 peer-reviewed articles and book chapters, and 24 books in print or in preparation.     

Radiation injury of the lung after three-dimensional conformal radiation therapy

OBJECTIVE: The objective of this study is to describe the CT patterns of radiation injury in the lungs of patients who have undergone three-dimensional (3D) conformal radiation therapy (CRT). MATERIALS AND METHODS: Over a 36-month period, the chest CT scans of 19 patients with non-small cell lung cancer who were treated with 3D CRT were reviewed. CT scans were evaluated for findings of radiation injury (ground-glass opacities, consolidation, bronchiectasis, and volume loss). The presence, extent, and distribution of these findings were reached by consensus. RESULTS: Radiation pneumonitis limited to a small area immediately around the tumor was present in all patients who were imaged within 3 months after completion of the treatment (n = 7). Radiation-induced fibrosis occurred in all patients (n = 19). Three distinct patterns of fibrosis were consistently present, and these were classified as modified conventional, masslike, and scarlike. Modified conventional fibrosis (consolidation, volume loss, and bronchiectasis similar to, but less extensive than, conventional radiation fibrosis) was seen in five patients. Masslike fibrosis (focal consolidation with traction bronchiectasis limited to the site of the original tumor) was seen in eight patients. Scarlike fibrosis (linear opacity in the region of the original tumor associated with moderate to severe volume loss) was seen in six patients. CONCLUSION: Three-dimensional conformal radiation therapy results in three patterns of radiation fibrosis that differ from the conventional radiation-induced lung injury. Knowledge of the full spectrum of these manifestations is useful in the correct interpretation of CT scans after 3D CRT.