Clinical Use of Permanent Pacemaker for Conversion of Intraatrial Reentry Tachycardia in Children

The use of the implanted atrial-based pacemaker to overdrive postsurgical intraatrial reentry tachycardia (IART) was evaluated in a large group of pediatric patients over a 14-year study period. The authors sought to determine the feasibility of this noninvasive technique in the management of this specialized population and to determine factors associated with successful conversion. They examined 128 manual overdrive attempts performed on 22 consecutive patients. There were 10 patients with post-Fontan repair, 7 with post-Mustard/Senning procedure, and 5 with miscellaneous lesion types. The number of IART episodes for overdrive pacing per patient ranged from 1 to 15. The first overdrive pacing attempt was successful in 63% (14/22) of the patients. The mean IART cycle length was 278 +/- 59 ms. The mean pacing rate for effective conversion of IART was 66 +/- 10% faster than the IART rate. By controlling for repeated measures for individual patients, three factors were found to be independently associated with a successful outcome: (1) lesion type other than Fontan surgery (P = 0.007), (2) lack of acceleration of IART with the overdrive attempt (P < 0.001), and (3) patient use of amiodarone with attempt (P = 0.005). There were three procedural complications: two inadvertent overdrive pacing episodes, and one episode of acceleration of IART cycle length and conduction resulting in need for cardioversion. Manual pacemaker overdrive conversion of IART is a useful adjunct in the management of postsurgical IART in the pediatric population and should be considered as an initial treatment option.     

An institutional experience with epidural analgesia in children and young adults undergoing cardiac surgery

Background: Allowing spontaneous respiration after cardiac surgery eliminates complications related to mechanical ventilation and optimizes cardiopulmonary interaction. Epidural analgesia has been proposed to promote early extubation after cardiac surgery. Objective: To identify the characteristics of patients with epidural analgesia and safety profiles with respect to the timing of extubation following cardiac surgery. Design and method: A retrospective chart review of patients who underwent cardiac surgery during a 5‐year period. Demographic, procedural, and perioperative variables were analyzed to investigate factors that affect the timing of extubation. Results: A total of 750 records were reviewed. The patients’ median age was 12 months, and 52% were infants (<1 year). Seventy‐five percent of the patients utilized cardiopulmonary bypass. The study population was classified into three groups according to the timing of extubation: 66% were extubated in the operating room or upon arrival at the PICU (Immediate), 15% were extubated within 24 h (mean, 10.8 h; 95% CI, 9.0–12.6) (Early), and 19% were extubated after 24 h (Delayed). For the Immediate and Early groups, multivariate logistic regression identified young age, increased cross‐clamp time, and inotrope score as independent risk factors for the need for mechanical ventilation. Postextubation respiratory acidosis (mean P_aCO₂, 50 mmHg; 95% CI, 49–51) was well tolerated by all patients. There were no neurologic complications related to the epidural technique. Conclusion: Epidural analgesia in children undergoing cardiac surgery provides stable analgesia without complications in our experience.     

Shelf life of cefuroxime eye-drops when dispensed in artificial tear preparations

There has recently been a clinical demand for cefuroxime formulated as an eyedrop. Cefuroxime exhibits a broad spectrum of activity against most common ocular infections and is considered to be less toxic to the compromised epithelium than some other topical antibiotics. A formulation in an artificial tear solution would be expected to enhance drug penetration by prolonging pre-corneal drug retention, and the presence of a preservative might enable a suitable formulation to be given a shelf life of more than 24 hours. This paper reports studies on the stability of cefuroxime 50mg/ml (5 per cent) in artificial tear solutions, sodium chloride eye-drops and in solutions of benzalkonium chloride, hypromellose or water for injections. Cefuroxime was assayed by high performance liquid chromatography. The method had a coefficient of variation of 0.23 per cent at the concentration investigated and recovery of added cefuroxime was 100 per cent. The preparation of cefuroxime in artificial tear solutions which were preservative free or contained benzalkonium chloride less than 0.002 per cent appeared to be physically stable. Preparation of cefuroxime in Sno Tears also produced a stable solution. This preparation can be given a shelf life of 28 days at 4C, 24 hours at 25C and 14 days if stored in a domestic refrigerator, enabling a full course of treatment to be given on a single visit to the pharmacy.     

Quadricuspid Aortic Valve Diagnosed by Multiplane Transesophageal Echocardiography

The usefulness of multiplane transesophageal echocardiography in the diagnosis of quadricuspid aortic valve is described.
quadricuspid aortic valve, multiplane transesophageal echocardiography     

Health promotion in the market-place: patient satisfaction as the basis of a marketing strategy

This article looks at prevention in the context of recent policyinitiatives in the UK which have created new roles and new opportunitiesfor general practitioners (GPs) and primary care. One such opportunityis the potential to actively market preventive services in orderto retain and attract patients in a competitive market. We firstdescribe this context and then provide an example of how a patientsatisfaction survey can be an effective market-research toolThe results from a district-wide survey are evaluated in termsof socio-demographic differences which stratify the patientmarket into segments which are aware of, users of and are satisfiedwith preventive services and those who are not. This articleillustrates how GPs can use data of this kind when developinginvestment and marketing strategies.     

Preparation and properties of Nα-Bpoc-amino acid pentafluorophenyl esters

The preparation and properties are reported of several N^x-Bpoc -amino acid pentafluorophenyl esters, including those bearing tert-butyl-, allyl- and trityl-based protecting groups. These derivatives have been used in the solid-phase peptide synthesis of sevral short peptides.     

The Production of Schistocytes by Fibrin Strands (A Scanning Electron Microscope Study)

The relationship between intravascular coagulation and schistocyte formation has been adequately documented in animal experiments and in in vitromodels. A case report is presented of a patient who suffered from micro-angiopathic hemolytic anemia during life as a result of disseminated gastricadenocarcinoma. The fibrin microclots found in his vasculature on postmortemexamination indicate that in intravascular coagulation, both in the human andin the experimental animal, fibrin initially polymerizes in the form of finefibrin strands. These strands, the main etiologic factor in producing schistocytes, are constantly being lysed or rendered amorphous, and rarely persistin postmortem tissues except under unusually favorable conditions. Postmortem histologic study of one case where such favorable conditions didexist indicates the essential identity of the pathologic process in man and inexperimental animals.

Submitted on May 26, 1969 Accepted on July 22, 1969