Systemic-pulmonary polytetrafluoroethylene shunts in palliative operations for congenital heart disease. Revival of the central shunt

The concept of central shunting in smaller children with the Waterston shunt was initially well accepted. It has been abandoned because of the difficult estimation of lumen size, preferential flow to the right side, and difficulty in the take-down of the shunt. We have replaced the Waterston shunt with a short segment of polytetrafluoroethylene between the ascending aorta and the main pulmonary artery. From January 1979 to December 1986, 190 shunt operations were performed in 157 patients, with the use of 26 classic Blalock-Taussig shunts (13.7%), six Waterston shunts (3.1%), nine Glenn shunts (4.7%), 80 central aortopulmonary polytetrafluoroethylene shunts (42.2%), and 69 modified Blalock-Taussig shunts (36.3%). Polytetrafluoroethylene grafts were used for 149 of the 190 (78.4%) shunts. Overall mortality was 15.2%, with nine early deaths (4.7%) and 20 late deaths (10.5%). Deaths were due to the complex nature of the congenital anomaly or definitive surgical repair. The patients weighed from 1.6 to 48 kg and ages ranged from 1 day to 22 years. We have modified our technique so that (1) graft length is less than 0.5 cm and both ends are beveled, (2) the aortotomy is fashioned with a punch, (3) the center of the polytetrafluoroethylene graft is never clamped, (4) heparin is given during the construction of the shunt, and (5) aspirin (10 mg/kg/day) is administered daily. Patency ranges from 1 to 4 years. We conclude that the polytetrafluoroethylene shunt provides excellent palliation and that the central shunt, in the smaller child and infant, offers the benefits of shunting without distortion of the peripheral pulmonary arteries.     

Differences in bereavement reactions within couples following death of a child

Differences in distress within couples who have experienced the sudden death of a child were examined. Results from two independent samples (N = 50 couples and N = 60 couples) were compared. The SCL-90-R and the BSI were used to measure global psychological distress and distress in nine symptom dimensions. Paired t tests revealed similar findings in the two samples: Within couples, women had significantly greater global distress than men and significantly greater distress than men in most symptom dimensions. Hostility scores within couples were similar and indicated a high level of hostility. The findings may explain relational problems observed within bereaved couples. Interventions designed to help couples cope with their differences and their hostility may decrease relational problems. © 1996 John Wiley & Sons, Inc.     

Percutaneous intravascular retrieval of embolised fragments of long-term central venous catheters

Embolisation of a catheter fragment is a rare mechanical complication of long-term central venous access devices. From 1995 to 1999 we observed 10 cases: the cause of embolisation was the 'pinch-off syndrome' in half of the cases, and in 8 cases out of 10 the fragment had embolised in the pulmonary arterial vessels. Percutaneous transvenous retrieval was successful in all cases; it was performed mainly (8 cases out of ten) through the left transfemoral route, using a single-snare-loop device sometimes associated with a pig-tail catheter. We had no mortality and no major complications. On the basis of our experience, we believe that catheter embolisation of long-term central venous devices can be effectively prevented by adequate insertion technique, proper management of the device during its clinical use, and accurate removal technique. Nonetheless, should catheter em-bolisation occur, the patient should be referred to a Centre with adequate experience in the field of interventional radiological techniques. Should the radiological retrieval procedure fail, evidence from the literature suggests that leaving the fragment in embolisation site might be safer than open extraction by surgical thoracotomy, particularly in oncological patients with reduced life expectancy.     

Use of CAM in local African-American communities: community-partnered research

Although previous national surveys have shown an increase in the use of complementary and alternative medicine (CAM) in the U.S. population, racial and ethnic minority populations were under-represented in these surveys. As a result, a profile of the CAM user as white, female, affluent, middle-aged and well educated has emerged. Representing the mainstream population, these previous studies did not take into account the racial and ethnic minority populations who may have their own healing traditions and who may hold different beliefs, use different terminology, and have unique patterns of CAM use. In partnership with community-based organizations and community residents, a culturally sensitive survey instrument and protocols were designed and tested to gather data on lower income, urban African-Americans' use of, attitudes toward, and understanding of CAM. The major findings of this pilot research are 1.) Community-partnered research can help researchers gain access to sensitive data and design culturally appropriate studies; 2.) CAM terminology varies by cultural group; 3.) Certain forms of CAM (folk or family practices) are commonly found in African-American populations; and 4.) Factors that affect CAM use--including age, lack of access to conventional medicine, cultural heritage, and dissatisfaction with conventional medicine.     

Color Doppler sonography in the diagnosis and monitoring of arterial complications after liver transplantation

PURPOSE: We assessed the usefulness of color Doppler imaging in the diagnosis and monitoring of arterial complications after liver transplantation. METHODS: Subjects were 142 liver transplant recipients who underwent serial color Doppler sonographic evaluations of the hepatic arteries after surgery. Patients with abnormal sonographic findings underwent subsequent angiography. RESULTS: Eighteen subjects experienced 20 hepatic arterial complications (13 thromboses and 7 stenoses). In 7 of the 13 thrombosis incidents, hepatic arterial obstruction occurred within a month of surgery and was evident from the absence of Doppler signals; angiography confirmed the absence of hepatic arterial perfusion in these cases. In the other 6 thrombosis cases, the thrombosis developed 3 or more months after surgery and became apparent from the absence of color Doppler signals at the level of the main arterial trunk and the presence of intraparenchymal "tardus parvus" waveforms. In these cases, angiography showed obstruction of the main arterial trunk and the development of compensatory collateral vessels. In 3 of the 7 cases of stenosis, high flow velocities were recorded at the site of the narrowing, and intrahepatic tardus parvus waveforms were present. In the other 4 stenosis cases, the site of stenosis could not be identified, but intraparenchymal tardus parvus waveforms were recorded. CONCLUSION: The use of color Doppler sonography allows the early diagnosis of hepatic arterial complications after liver transplantation. Tardus parvus waveforms indicated severe impairment of hepatic arterial perfusion, from either thrombosis or severe stenosis. The presence of these waveforms enhanced the accuracy of color Doppler diagnosis (100% positive predictive value), and their detection should prompt angiography.