Total cavopulmonary anastomosis using atrial septal flap: technique and early results

Introduction The Fontan procedure has undergone many modifications to avoid atrial arrhythmias and thrombus formation. We used patient’s interatrial septum as a flap to direct the inferior venacaval blood to the superior venacava. Methods Seventeen patients, aged 1 to 17 years, underwent modified total cavopulmonary anastomosis. Interatrial septum was used to create the inner half of the atrial tunnel, outer half being formed by right atrial free wall. Post-operatively, all patients underwent echocardiography. Seven patients underwent 24 hour ambulatory Holter monitoring and 6 patients underwent cardiac catheterization and cineangiography. Results There was one early death due to low cardiac output. One patient had transient supraventricular arrhythmia. Two patients had singnificant pleural effusion. Holter Monitoring reveled sinus rhythm in all 7 patients studied. Follow up ranged from 18 to 60 months and patients were evaluated as they came for follow up. Long term follow up is currently being compiled. There was one late death from a non-cardiac cause. The remaining patients were in New York Heart Association (NYHA) Class I or II. All patients were in sinus rhythm. Echocardiography and cineangiography revealed absence of obstruction or leak. Conclusions Total cavopulmonary anastomosis using autogenous atrial septum is a useful modification for classical cavopulmonary anastomosis and provides good early results.     

Period, age, and cohort effects on substance use among young Americans: a decade of change, 1976-86

In an earlier article in this Journal, we reported analyses that differentiated among period, age, and cohort effects on substance use among American youth 18 to 24 years old, from the high school classes of 1976 to 1982 during the period of 1976 to 1982. The present analyses extend the classes and years to 1986, and the age range to 18-28. A cohort-sequential design is employed, based on annual surveys of nationally representative samples of high school seniors, plus annual follow-up surveys of each senior class. Twelve different classes of drugs, both licit and illicit, are examined. Several different types of period, age, and cohort effects over the last decade are identified. Alcohol use (monthly and occasions of heavy use), and the use of marijuana, cocaine, amphetamines, methaqualone, barbiturates, LSD, psychedelics other than LSD, and tranquilizers all showed period effects. Occasions of heavy drinking, cigarette smoking, monthly and daily use of alcohol, and annual prevalence of cocaine, amphetamines, barbiturates, LSD, and narcotics other than heroin showed age effects. Class effects were seen for cigarette smoking and daily marijuana use.     

Incisional hernia recurrence through genomic profiling: a pilot study

Purpose

Although situational risk factors for incisional hernia formation are known, the methods used to determine who would be most susceptible to develop one are unreliable. We hypothesized that patients with recurrent incisional hernias may possess unique gene expression profiles.

Methods

Skin and intact fascia were collected from 15 normal control (NC) patients with no hernia history and 18 patients presenting for recurrent incisional hernia (RH) repair. Microarray analysis was performed using whole genome microarray chips on NC (n = 8) and RH (n = 9). These samples were further investigated using a pathway-specific PCR array containing fibrosis-related genes.

Results

Microarray data revealed distinct differences in the gene expression profiles between RH and NC patients. One hundred and sixty-seven genes in the skin and 7 genes in the fascia were differentially expressed, including 8 directly involved in collagen synthesis. In particular, GREMLIN1, or bone morphogenetic protein antagonist 1, was under expressed in skin (fold = 0.49, p < 10^?7, q = 0.0009) and fascia (fold = 0.23, p < 10^?4, q = 0.095) of RH patients compared with NC. The PCR array data supported previous reports of decreased collagen I/III ratios in skin of RH versus NC (mean = 1.51 ± 0.73 vs. mean = 2.26 ± 0.99; one-sided t test, p = 0.058).

Conclusion

To our knowledge, this is the first microarray-based analysis to show distinct gene expression profiles between the skin and fascia of RH and NC patients and the first report of an association between GREMLIN1 and incisional hernia formation. Our results suggest that gene expression profiles may act as surrogate markers that stratify patients into different groups at risk for hernia development prior to their initial surgery.     

Juvenile onset primary open-angle glaucoma: three case studies and review.

BACKGROUND: Common clinical characteristics of juvenile onset primary open-angle glaucoma (JPOAG) include increased intraocular pressure, optic nervehead damage, visual-field loss, and a normal-appearing iridocorneal angle by gonioscopy. Histologic analysis of the angle structures may show varying developmental abnormalities that are observed to be less obvious as age of onset increases. Individuals who are African-American, male in gender, and myopio, are at highest risk--particularly if a positive family history exists. A genetic locus for juvenile onset primary open-angle glaucoma has been isolated to the long arm of chromosome 1. CASE REPORTS: Three separate cases of JPOAG diagnosed in a 16-year-old African-American girl, a 9-year-old African-American boy, and a 28-year-old African-American woman are presented and reviewed. The symptoms, clinical presentation, disease progression, and treatment options are discussed in detail. CONCLUSION: Early recognition of this disease is possible through screening on all patients--particularly those who exhibit increased cupping with increased intraocular pressures and risk factors, such as youthful age, male gender, myopic refractive error, and African-American heritage with a positive family history of glaucoma. Family members should also be examined.     

Assessment of learning needs of nurse educators: continuing education implications.

Because of current structure, content, and outcomes of master's nursing curricula, administrators responsible for hiring nurse educators often have no choice but to employ clinical experts as teachers. This article reports on the results of an investigation designed to ascertain the self-reported learning needs of nurse educators in a southern state. This investigation confirmed that nurse educators have numerous learning needs specific to fulfillment of the nurse educator role. Findings suggest that learning needs differed according to the educator's level of academic preparation and type of employment setting. The results provide useful insights for individuals planning continuing educational offerings for nurse educators with varied backgrounds.     

Racial/Ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976-89.

BACKGROUND. This paper reports racial/ethnic differences in the use of licit and illicit drugs by high school seniors in the United States. METHODS. The study uses questionnaire data from annual, nationally representative surveys of seniors from 1976 through 1989. Combined sample sizes were 57,620 for 1976-79; 75,772 for 1980-84; and 73,527 for 1985-89. RESULTS. Native American had the highest prevalence rates for cigarettes, alcohol, and most illicit drugs; White students had the next highest rates for most drugs. Asian Americans had the lowest prevalence rates, and Black students had levels nearly as low except for marijuana. Prevalence rates for the Hispanic groups were mostly in the intermediate ranges except for relatively high cocaine use among the males. Trend patterns for most forms of drug use were similar across subgroups, although cigarette use declined more sharply for Black than White seniors, resulting in greater Black-White differences in recent years. CONCLUSIONS. This study, other school-based studies, and general population surveys all show relatively low levels of drug use by most non-White youth, especially Black Americans and Asian Americans. Multivariate analyses indicate that such subgroup differences in high school seniors' drug use are not primarily attributable to family composition, parents' education, region, or urban-rural distinctions.     

Documented arterial gas embolism after spinal epidural injection.

We report the case of a 90-year-old man with syncope, arrhythmia, cardiac ischemia, and neurologic deficit after undergoing spinal epidural injection for control of pain related to post-herpetic neuralgia. The diagnosis of arterial gas embolus was made after air was identified in the left ventricle of the heart on an abdominal computed tomographic scan. Emergency physicians should consider and rapidly diagnose this rare but potentially fatal complication of spinal epidural puncture.     

Regrowth of the rat biliary tree after 70% partial hepatectomy is coupled to increased secretin-induced ductal secretion

BACKGROUND & AIMS: After partial hepatectomy, liver regeneration occurs with the return of hepatocyte mass to normal, Limited data exist regarding the renewal of the biliary tree after partial hepatectomy. This study tested the hypothesis that, after partial hepatectomy, the biliary tree regenerates by proliferation of the remaining cholangiocytes, leading to an increase in secretin-induced ductal bile secretion. METHODS: After 70% partial hepatectomy, cholangiocyte proliferation was assessed in situ by morphometric analysis and In vitro by measurement of 3H-thymidine incorporation. Ductal secretion was estimated by measurement of secretin receptor gene expression and adenosine 3',5'-cyclic monophosphate (cAMP) levels in vitro and by the effect of secretin on ductal bile secretion in vivo. RESULTS: DNA synthesis was undetectable in control cholangiocytes, increased and peaked at day 3 after partial hepatectomy, and returned to normal by day 28. Morphometric analysis showed regrowth of the biliary tree beginning at day 1 with restoration by day 10. The expression of secretin receptor gene and secretin-induced cAMP levels and secretin- induced bicarbonate-rich choleresis increased during the period of bile duct renewal. CONCLUSIONS: After partial hepatectomy, the increase in secretin-induced ductal bile secretion observed during bile duct renewal results from proliferation of remaining cholangiocytes. (Gastroenterology 1996 Dec;111(6):1633-44)