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Abstract Nitrogen oxide (NOx) pollution is emerging as a primary environmental concern across Europe. While some large European metropolitan areas are already in breach of EU safety limits for NO2, this phenomenon does not seem to be only restricted to large industrialized areas anymore. Many smaller scale populated agglomerations including their surrounding rural areas are seeing frequent NO2 concentration violations. The question of a quantitative understanding of different NOx emission sources is therefore of immanent relevance for climate and air chemistry models as well as air pollution management and health. Here we report simultaneous eddy covariance flux measurements of NOx, CO2, CO and non methane volatile organic compound tracers in a city that might be considered representative for Central Europe and the greater Alpine region. Our data show that NOx fluxes are largely at variance with modelled emission projections, suggesting an appreciable underestimation of the traffic related atmospheric NOx input in Europe, comparable to the weekend-weekday effect, which locally changes ozone production rates by 40%.

As the United States (U.S.) moves toward the post-pandemic landscape, there remains a heightened need to increase the nursing workforce. The population continues to age, chronic illnesses are further exacerbated, and the highlight of the shortage of nurses weighed heavier while navigating care during Covid-19. This article examines nursing workforce improvement policies in a policy system where outcomes are either predicated by incremental decision-making or by punctuated changes. Punctuated Equilibrium Theory (PET) is posited to explain nursing policy trends and outcomes. Covid-19 created a punctuation in the healthcare system, leading to the "great resignation," the increase of travel nurses, and nurses working remotely via tele-health tools. What remains is the impact on nurse staffing policy and what will be done to provide nursing services moving into the future.

Functional near-infrared spectroscopy (fNIRS) allows for a reliable assessment of oxygenated blood flow in relevant brain regions. Recent advancements in immersive virtual reality (VR)-based technology have generated many new possibilities for its application, such as in stroke rehabilitation. In this study, we asked whether there is a difference in oxygenated hemoglobin (HbO 2 ) within brain motor areas during hand/arm movements between immersive and non-immersive VR settings. Ten healthy young participants (24.3 ± 3.7, three females) were tested using a specially developed VR paradigm, called "bus riding", whereby participants used their hand to steer a moving bus. Both immersive and non-immersive conditions stimulated brain regions controlling hand movements, namely motor cortex, but no significant differences in HbO 2 could be found between the two conditions in any of the relevant brain regions. These results are to be interpreted with caution, as only ten participants were included in the study.

Abstract: Rosa, A, Coleman, M, Haun, C, Grgic, J, and Schoenfeld, BJ. Repetition performance, rating of perceived discomfort, and blood lactate responses to different rest interval lengths in single-joint and multijoint lower-body exercise. J Strength Cond Res 37(7): 1350-1357, 2023-The purpose of this study was to examine the effects of different rest interval lengths (RILs) on repetition performance, rating of discomfort, and blood lactate responses during lower-body single-joint and multijoint exercises. This study used a counterbalanced design where each subject performed the Smith machine back squat (BS) and leg extension (LE) using 3 different RIL configurations (1, 2, and 3 minutes) in a randomized fashion. Data collection occurred over the span of 3 separate days. Volunteers were randomly allocated to perform the independent variables (RILs and exercises) in 1 of 12 potential configurations. The initial session was allotted for familiarization with the rating of discomfort scale and 10 repetition maximum testing. The other 2 sessions involved training with the different configurations of RIL length using both the BS and LE. Randomization ensured that the BS was performed first in one of the training sessions and the LE was performed first in the other session. Results indicated that longer RILs had a small positive effect on repetition performance, with longer rest durations allowing for more repetitions compared with shorter durations. The largest difference in repetition performance between RILs was observed between 1 minute and 2-3 minutes rest; there were trivial differences in repetition performance between 2 and 3 minutes rest for both the BS and LE. Blood lactate levels were slightly higher with longer RILs. Overall, BS showed greater increases in blood lactate compared with LE, and these differences were magnified over time. Exercise selection and RIL both influenced rating of discomfort, with LE producing less discomfort than BS and longer RILs reducing perceived discomfort. Our findings suggest that RIL influences the repetition performance, blood lactate, and rating of discomfort responses between single-joint and multijoint exercises., (Copyright © 2023 National Strength and Conditioning Association.)

The present review aims to explore and discuss recent research relating to the lactate response to resistance training and the potential mechanisms by which lactate may contribute to skeletal muscle hypertrophy or help to prevent muscle atrophy. First, we will discuss foundational information pertaining to lactate including metabolism, measurement, shuttling, and potential (although seemingly elusive) mechanisms for hypertrophy. We will then provide a brief analysis of resistance training protocols and the associated lactate response. Lastly, we will discuss potential shortcomings, resistance training considerations, and future research directions regarding lactate's role as a potential anabolic agent for skeletal muscle hypertrophy.

Clinical Scenario: Deformation of the arch, as measured by navicular drop (ND), is linked to lower-extremity musculoskeletal injuries. The short foot exercise (SFE) has been used to strengthen the intrinsic foot muscles that support the arch. Clinical Question: Does the SFE decrease ND in healthy adults? Summary of Key Findings: Three studies that examined the use of the SFE on ND were included. A randomized control trial that compared the SFE to a towel-curl exercise and a control group found no significant differences between the 3 groups. A randomized control trial compared the SFE to the use of arch support insoles in individuals with a flexible flatfoot and found a significant improvement in the SFE group. A prospective cohort study, without a control group, reported a significant decrease in ND following a 4-week SFE intervention without a regression at an 8-week follow-up. Overall, two of the three studies reported a significant reduction in ND following an SFE. Clinical Bottom Line: There is preliminary data supporting the use of the SFE to decrease ND-particularly in individuals with a flexible flatfoot. However, issues with the study designs make it difficult to interpret the data. Strength of Recommendation: Due to limited evidence, there is grade B evidence to support the use of the SFE to decrease ND.

It has been proposed that superior muscle hypertrophy may be obtained by training muscles predominant in type I fibers with lighter loads and those predominant in type II fibers with heavier loads., Purpose: To evaluate longitudinal changes in muscle strength and hypertrophy of the soleus (a predominantly slow-twitch muscle) and gastrocnemius (muscle with a similar composition of slow and fast-twitch fibers) when subjected to light (20-30 repetition maximum) and heavy (6-10 repetition maximum) load plantarflexion exercise., Methods: The study employed a within-subject design whereby 26 untrained young men had their lower limbs randomized to perform plantarflexion with a low-load (LIGHT) and a high-load (HEAVY) for 8 weeks. Muscle thickness was estimated via B-mode ultrasound and maximal strength was determined by isometric dynamometry., Results: Results showed that changes in muscle thickness were similar for the soleus and the gastrocnemius regardless of the magnitude of load used in training. Furthermore, each of the calf muscles demonstrated robust hypertrophy, with the lateral gastrocnemius showing greater gains compared to the medial gastrocnemius and soleus. Both HEAVY and LIGHT training programs elicited similar hypertrophic increases in the triceps surae. Finally, isometric strength increases were similar between loading conditions., Conclusions: The triceps surae muscles respond robustly to regimented exercise and measures of muscle hypertrophy and isometric strength appear independent of muscle fiber type composition. Moreover, the study provides further evidence that low-load training is a viable strategy to increase hypertrophy in different human muscles, with hypertrophic increases similar to that observed using heavy loads., (© 2020 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

We aimed to investigate the effects of resistance training (RT) combined with no-load isometric actions (iso-holds) during the inter-set recovery period versus RT that involves passive inter-set rest on muscular strength, muscular hypertrophy, and muscular endurance in resistance-trained men. Twenty-seven resistance-trained male volunteers were randomly assigned to either a traditional group (TRAD) that performed a hypertrophy-oriented RT routine with the rest intervals spent passively ( n = 13) or to a group that supplemented traditional RT with iso-holds (ISO) for the working muscle group between each set ( n = 14). Training for both routines consisted of three weekly sessions performed for 8 weeks. Three sets of 8-12 repetitions were performed per exercise. A 2-min rest interval was afforded between sets; the ISO group performed iso-holds for the first 30 s of each rest interval and then recovered for the final 90 s. Maximal strength was assessed using the one repetition maximum (1RM) tests in the leg press and bench press. Upper-body muscle endurance was assessed by performing the bench press to failure at 50% of 1RM. Muscle thickness (MT) of the elbow flexors, elbow extensors, mid-thigh, and lateral thigh was assessed using B-mode ultrasound. Results indicated a favorable effect of ISO on MT in the mid-thigh. Alternatively, there was a possible detrimental effect for ISO on leg press strength. No other notable differences were seen between conditions. In conclusion, the use of inter-set iso-holds may be a time-efficient strategy to enhance development of the quadriceps femoris; conversely, it may be detrimental to maximizing lower body strength., (Copyright © 2020 Schoenfeld, Grgic, Contreras, Delcastillo, Alto, Haun, De Souza and Vigotsky.)

Resistance training volume, determined by the number of sets performed (set-volume) is considered one of the key variables in promoting muscle hypertrophy. To better guide resistance exercise prescription for weekly per-muscle training volume, the purpose of this paper is to provide evidence-based considerations for set-volume ratios between multi-joint (MJ) and single-joint (SJ) exercises so that practitioners can better manage prescription of training volume in program design. We analyzed this topic from three primary areas of focus: (1) biomechanical and physiological factors; (2) acute research; and (3) longitudinal research. From a biomechanical and physiological standpoint, when considering force production of different muscle groups, the moment arm of a given muscle, "motor abundance", the link between biomechanics and exercise-induced fatigue, as well as the amount of time in voluntary muscle activation, a logical rationale can be made for SJ exercises producing greater hypertrophy of the limb muscles than MJ exercises (at least from specific exercises and under certain conditions). This would mean that sets for a MJ exercise should be counted fractionally for select muscles compared to an SJ exercise (i.e., less than a 1:1 ratio) when prescribing set-volumes for given muscles. When considering results from acute studies that measured muscle activation during the performance of SJ and MJ exercises, it seems that MJ exercises are not sufficient to maximize muscle activation of specific muscles. For example, during performance of the leg press and squat, muscle activation of the hamstrings is markedly lower than that of the quadriceps. These results suggest that a 1:1 ratio cannot be assumed. Current longitudinal research comparing the effects of training with MJ vs. SJ or MJ + SJ exercises is limited to the elbow flexors and the evidence is somewhat conflicting. Until more research is conducted to derive stronger conclusions on the topic, we propose the best advice would be to view set-volume prescription on a 1:1 basis, and then use logical rationale and personal expertise to make determinations on program design. Future research should focus on investigating longitudinal hypertrophic changes between MJ and SJ in a variety of populations, particularly resistance-trained individuals, while using site-specific measures of muscle growth to more systematically and precisely compute effective individualized set-volumes.

Nitrogen oxide (NO x ) pollution is emerging as a primary environmental concern across Europe. While some large European metropolitan areas are already in breach of EU safety limits for NO 2 , this phenomenon does not seem to be only restricted to large industrialized areas anymore. Many smaller scale populated agglomerations including their surrounding rural areas are seeing frequent NO 2 concentration violations. The question of a quantitative understanding of different NO x emission sources is therefore of immanent relevance for climate and air chemistry models as well as air pollution management and health. Here we report simultaneous eddy covariance flux measurements of NO x , CO 2 , CO and non methane volatile organic compound tracers in a city that might be considered representative for Central Europe and the greater Alpine region. Our data show that NO x fluxes are largely at variance with modelled emission projections, suggesting an appreciable underestimation of the traffic related atmospheric NO x input in Europe, comparable to the weekend-weekday effect, which locally changes ozone production rates by 40%.

Objectives: In symptomatic patients, performing a primary repair of tetralogy of Fallot (TOF), irrespective of age or placing a shunt, remains controversial. The aim of the study was to analyse the policy of primary correction., Methods: Between May 2005 and May 2012, a total of 87 consecutive patients with TOF, younger than 6 months of age, underwent primary correction. All patients had one source of pulmonary blood flow, with or without a patent ductus arteriosus. The median age at surgery was 106 ± 52.3 days (8-180 days). Twelve patients (13.8%) were newborns. Two groups were analysed: group I, patients <1 month of age; group II, patients between 2-6 months of age., Results: There was no early or late death at 7 years of follow-up. There was no difference in bypass time or hospital stay between the two groups, but the Aristotle comprehensive score (P < 0.0001), ICU stay (P = 0.030) and the length of ventilation (P = 0.014) were significantly different. Freedom from reoperation was 87.3 ± 4.3% and freedom from reintervention was 85.9 ± 4.2% at 7 years, with no difference between the two groups. Neurological development was normal in all patients, but 1 patient in Group II had cerebral seizures and showed developmental delay. Growth was adequate in all patients, except those with additional severe non-cardiac malformations that caused developmental delay. Eighty-five per cent of the patients were without cardiac medication., Conclusions: Even in symptomatic neonates and infants <6 months of age, primary repair of TOF can be performed safely and effectively. One hundred per cent survival at 7 years suggests that early primary repair causes no increase in mortality in the modern era. Shunting is not necessary, even in symptomatic newborns, thus avoiding the risk of shunt-related complications and repeated hospital stays associated with a staged approach.

Objective: The objective of this study was to estimate the morbidity according to observed complications after congenital heart surgery over 1-year period., Methods: The previously established list of conditions prone to affect patients' well-being or increase cost of in-hospital stays was used systematically to score the severity of postoperative complications from 1 to 4 points. The morbidity score was calculated by adding the scores of observed complications. When the sum amounted to more than 5 points, a morbidity score of only 5 points was attributed. If no complication was detected, a score of 0.5 points was assigned. The resulting morbidity scores were correlated with the length of stay in the intensive care unit (ICU) and in the hospital, the duration of mechanical ventilation, and Aristotle complexity scores., Results: A total of 542 primary procedures performed in the year 2011 were studied. Aristotle basic and comprehensive scores amounted to 7.78 ± 2.65 and 10.15 ± 3.83, respectively. Mortality was 1.85% (10/542). The standardized ratio of surgical performance reached 103.10%. Total cavopulmonary connection with extracardiac fenestrated conduit constituted the most frequent operation (n = 34). No complication was observed following 183 (33.8%) procedures. More than two complications were observed in 114 cases (21%). The three most frequent unfavorable conditions were "mechanical ventilation 25 to 95 hours" (n = 150), low cardiac output syndrome (n = 56), and cardiac arrhythmia requiring medication (n = 50). The estimated mean morbidity score amounted to 2.26 ± 1.80 points. Scores ranged from 0.68 ± 0.50 for primary closure of atrial septal defect to 4.50 ± 0.79 for the Norwood procedure. They were perfectly related to the length of ICU stay and to the duration of mechanical ventilation (Spearman coefficient r = 1). Correlation was high with the length of hospital stay (r = 0.83), Aristotle basic score (r = 0.89) (r = 0.96), and comprehensive score (r = 0.94) (C-index = 0.97). The observed mean morbidity score was statistically not different from the expected mean morbidity score according to the basic Aristotle complexity: p = 0.73., Conclusion: Quantification of morbidity indicates the length of ICU stay and the duration of mechanical ventilation as the best surrogates for morbidity. Such benchmarking and scoring of observed postoperative complications paves the way for an accurate assessment and improvement of quality care in congenital heart surgery., (Georg Thieme Verlag KG Stuttgart · New York.)

Improved results have evolved from the modified Norwood procedure (NP). This study compares the incidence of interventions after NP with the Sano (n = 37) and modified Blalock-Taussig (BT n = 70) shunt. Incidence, location, interval of interventions, and weight were retrospectively analysed for 107 neonates undergoing NP during the period from October 2002 to December 2009. Forty-six (43.0 %) patients underwent interventions, mostly for dilatation of the aortic arch ([DAA] n = 26 [24.3 %]; Sano n = 10, BT n = 16, p = 0.6), dilatation of the shunt ([DS] n = 15 [14.0 %]; Sano n = 11, BT n = 4; p = 0.002), or closure of aortopulmonary collaterals ([APC] n = 15 [14.0 %]; Sano n = 3, BT n = 12; p = 0.08). Mean interval after NP and body weight at DAA, DS, and APC were 72.4 ± 18.9, 108.5 ± 15.8, and 110.7 ± 17.8 days and 4.5 ± 1.3, 4.9 ± 1.9, 5.3 ± 1.2 kg, respectively. The interventions were not associated with mortality but with a greater rate of complications (9 of 46 [21.4 %]) compared with the rate after diagnostic catheterization (0 of 45, p = 0.03). Complications included closure of the femoral or subclavian artery (n = 5), cerebral embolic or bleeding events (n = 4), cardiopulmonary resuscitation (n = 3), and temporary heart block (n = 2). Actuarial survival was similar from the postoperative month 8 onward at 78.6 ± 4.9 % (95 % confidence interval [CI] 67.0-86.5 %) for Sano and 78.4 ± 6.8 % (95 % CI 61.4-88.6 %) for BT (p = 0.95). Interventions after NP were common irrespective of shunt type. However, a significantly greater rate of shunt interventions was noted in the Sano group. In particular, interventions addressing the aortic arch and the shunt were related with a significant rate of complications.

Background: This study analyzed the long-term outcome after operations for open aortic valvotomy, specifically looking at the preservation of the native aortic valve., Methods: Between 1983 and 2011, 34 neonates with critical aortic stenosis underwent open valvotomy. The mean age at operation was 15 days (range, 1 to 28 days). Follow-up was 100% complete., Results: Three patients died early. The probability of survival was 91.2%, with a mean follow-up of 11 years (range, 10 months to 21 years). Event-free survival was 77%, 68%, 68%, and 57% at 5, 10, 15, and 20 years, respectively, and freedom from aortic valve replacement was 93%, 83%, 68%, and 57%. Tricuspid valve morphology revealed the best outcome, with event-free survival of 90% (p = 0.006) and 100% freedom from aortic valve replacement (p = 0.0012) at 20 years of follow-up. All but 4 patients were in New York Heart Association class I; 77 % of all patients were without medication., Conclusions: In neonates, predictable and consistent long-term results can be accomplished by open valvotomy in any type of valve morphology, even in an asymmetric arrangement. Operative repair not only offers a 90% survival benefit in the long-term but also preserves the native aortic valve in most patients. Clearly superior results were achieved in tricuspid valve morphology, in which there was no need for aortic valve replacement at 20 years of follow-up., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of study was to analyse the mid-term results of the Ross-Konno procedure in infants., Methods: Between 2000 and 2011, 16 infants, including five newborns, with complex left ventricular outflow tract (LVOT) obstruction underwent the Ross-Konno procedure. Twelve patients (75%) required multiple concomitant procedures such as: mitral valve (MV) surgery (four patients), resection of endocardial fibroelastosis (EFE) and myectomy (six patients), closure of ventricular septal defect (four patients) and aortic arch reconstruction (three patients). The median age at operation was 4.2 months (from 6 to 333 days)., Results: There was one late death with a median follow-up of 6.2 years. Actuarial survival is 93.3% at 5 years follow-up (95% confidence interval: 61.2-99.0). Postoperatively, two patients required extracorporeal membrane oxygenation support and one MV replacement. The median length of stay in hospital was 30 days (from 11 to 77 days). At 5 years of follow-up, seven patients had no aortic regurgitation (AR) and nine patients (56%) had trivial AR with no gradient in LVOT. Freedom from mitral regurgitation (MR) ≥ moderate or MV replacement was 70%. MR was associated with either structural abnormalities of MV or with development of EFE. Freedom from redo was 81 and 53% at 1 and 5 years of follow-up. Sixty percent of patients are without medication. All patients are in sinus rhythm., Conclusions: With the technical aspects of this procedure well accomplished, the risk of surgery is minimal and functional outcome is encouraging. However, early postoperative morbidity is significant. At the mid-term follow-up, there was no residual or recurrent outflow tract obstruction and excellent function of the neoaortic valve. A high incidence of MR associated with the development of EFE and structural abnormalities of the MV is worrisome; however, concomitant MV surgery is not associated with increased mortality. In the case of the development of EFE, an early indication for operation might protect MV function. The reoperation rate is high due to early conduit failure.

Objectives: With improved short-term outcomes the right ventricular to pulmonary artery shunt (Sano) has become the preferred pulmonary blood source in the Norwood procedure in many centres. However, most studies analysed consecutive cohorts, with a first modified Blalock-Taussig shunt (BT) followed by the Sano cohort. Besides, neither comprehensive preoperative risk analysis nor outcome beyond 1 year of age was investigated., Methods: This study reviews 109 neonates undergoing the Norwood procedure in the same interval between October 2002 and December 2009. The Sano (38) or BT shunt (71) was assigned according to the surgeon's preference. Two neonates subsequently underwent successful biventricular repair and were excluded. The Aristotle comprehensive score (ACS) was used to evaluate preoperative risk, with high-risk patients (n = 39) classified as having an ACS ≥ 20, and low-risk patients (n = 68) given an ACS <20., Results: Mean Aristotle score at the Norwood operation was 18.8 ± 0.4 and 18.9 ± 0.3 (P = 0.9) in Sano and BT, respectively. Mean follow-up interval was 4.1 ± 2.1 years (range: 1.7-8.9 years). Actuarial survival was similar, stabilizing from the 8th postoperative month onwards at 78.6 ± 4.9% (95% CI: 67.0-86.5%) for Sano and 78.4 ± 6.8% (95% CI: 61.4-88.6%) for BT; P = 0.95. Midterm actuarial survival was higher in low-risk patients, 88.2 ± 3.9% (95% CI: 77.8-93.9%) than in high-risk patients: 61.5 ± 7.8% (95% CI: 44.5-74.7%, P = 0.0003). No survival benefit was detected in low- or high-risk cases for either shunt type. Risk factors for midterm mortality were cardiorespiratory failure requiring ventilation (13/34, P = 0.004), and ACS ≥ 20 (15/39, P = 0.001), but not shunt type (8/37, P = 0.95). Increased number of shunt-related interventions before the Glenn procedure were noted with Sano (32.4 versus 6.5%, P = 0.002)., Conclusions: Preoperative risk factors, regardless of shunt type, influence midterm survival after the Norwood procedure with an excellent outcome in low-risk patients, while high-risk cases still incur a significant mortality. Sano shunt interventions occurred with increased numbers. Although, Sano shunt may be the only feasible option in some instances, given the possible negative effects of ventriculotomy on right ventricle function, the widespread use of Sano shunt should be reconsidered.

Background: Patients with combined aortopulmonary window (APW) and interrupted aortic arch (IAA) malformations are rarely seen. We reviewed cases with such association with emphasis on surgical management and long-term outcome., Methods: 109 patients with IAA and 25 patients with APW were operated upon between 1981 and 2011. The clinical records, operation and follow-up data were analyzed. Long-term outcome was completed with the help of either outpatient data or inquiring. Related literature was investigated., Results: Combined APW/IAA was found in 8 cases: 7.3% (8/109) of those with IAA diagnosis and 32% (8/25) with APW. All APWs were proximal. 7 patients had interruption type A. A ventricular septal defect (VSD) was associated in one case only. Median age at surgery was 10 days. The two first patients were operated upon without cardio-pulmonary bypass (CPB) and one died during operation. The other six underwent single stage approach under CPB with no death: overall early mortality of 12.5% (⅛). APW was closed with one or two patches; aortic arch was reconstructed either directly (extended end-to-side anastomosis) or by patch augmentation. There was no late death and no reoperation during mean follow-up of 118 months (range 1-360 months). Six patients were in functional NYHA class I, the remainder in class II. The cumulative APW/IAA incidence from literature varies between 4.9% (56/1105) and 22.2% (42/189). Early mortality reaches 15.1% (8/53) (95% CI: 6.8% - 27.6%)., Conclusion: Neonatal repair with thorough mobilization of the aortic arch and extended end-to-side anastomosis or use of patch augmentation carries potential for the best early and late outcome for combined APW/IAA malformation., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: The aim of this study was to develop a morbidity score based on observed postoperative complications after congenital heart surgery., Methods: Conditions or diseases that impair patients after congenital heart surgery or increase costs of hospital stay were called complications and attributed to scores ranging from 1 (mild) to 4 (severe) points, according to estimated severity or costliness. 'No complication' was assigned 0.5 points. From January to March 2011, scores for each observed 'complication' for every main (primary) surgical procedure were recorded and a morbidity score was calculated. In conformity with the Aristotle score methodology, if the sum of observed complication scores amounted to more than 5 points, a morbidity score of only 5 points was attributed. The estimated morbidity score was compared with the morbidity score attributed by the Aristotle basic complexity (ABC) score., Results: One hundred and thirty-nine primary procedures were carried out. The mean ABC and Aristotle comprehensive complexity scores reached 8.31 ± 2.52 and 9.62 ± 3.47 points, respectively. Two patients died. No complication was detected after 46 procedures. Overall, there were 185 listed 'morbidity' conditions in connection with the other 93 surgical procedures, rendering a total score of 385 points. The most frequent event was 'mechanical ventilation 25-95 h': n = 39. The mean morbidity score was 2.14 ± 1.63. The morbidity scores ranged from 0.5 points (n = 46) to 5 points (n = 23) with a median of 2.0 points. The scores for 11 different procedures that were performed at least five times positively correlated with the corresponding Aristotle morbidity scores: Pearson's coefficient r = 0.75. But the morbidity score for bidirectional cavopulmonary anastomosis (3.14 ± 1.77) was higher than the corresponding Aristotle morbidity score (2.0). It was lower for 'conduit placement, right ventricle to pulmonary artery': 1.08 ± 0.97, versus 2.0, and for arterial switch operation: 2.08 ± 1.11, versus 3.0., Conclusions: The reported morbidity scores need to be tested on larger series and in different institutions. The introduced morbidity score has the potential to quantify postoperative complications accurately. Its estimation over time can facilitate the assessment of quality of congenital heart surgery. It will allow comparison of morbidity outcomes across institutions with different case-mixes.

Planning and budgeting for congenital heart surgery depend primarily on how closely reimbursement matches costs and on the number and complexity of the surgical procedures. Aristotle complexity scores for the year 2010 were correlated with hospital costs and with reimbursement according to the German diagnosis-related groups (DRG) system. Unit surgical performance was estimated as surgical performance (complexity score × hospital survival) times the number of primary procedures. This study investigated how this performance evolved during years 2006 to 2010. Hospital costs and reimbursements correlated highly with Aristotle comprehensive complexity levels (Spearman r = 1). Mean costs and reimbursement reached 35,050 ± 32,665 and 31,283 ± 34,732, respectively, for an underfunding of 10.7%. Basic and comprehensive unit surgical performances were respectively 3036 ± 1009 and 3891 ± 1591 points in 2006. Both performances increased in sigmoid fashion to reach 3883 ± 1344 and 5335 ± 1314 points, respectively, in 2010. Top performances would be achieved in year 2011, and extrapolated costs would comprise about 19,434,094.92 (95% confidence interval, 11,961,491.22-22,495,764.42). The current underfunding of congenital heart surgery needs correction. The Aristotle score can help to adjust reimbursement according to complexity of procedures. Unit surgical performance allows accurate budgeting in the current German DRG system.

Objective: Anatomic correction of corrected transposition of the great arteries, utilizing the morphologic left ventricle as a systemic pumping chamber, is considered the preferred method. The purpose of the study was to analyze the intermediate functional outcome following anatomical correction., Methods: Between 1997 and 6/2010, 23 patients with corrected transposition of the great arteries and associated lesions underwent anatomical correction. Seventeen (74%) and six patients (26%) had situs solitus {S,L,L} and situs invs {I,D,D}, respectively. Fifteen patients (65%) had undergone 18 palliations before the corrective operation. The median age at palliation was 0.23 years, with a range of 0.016-8.4 years. A corrective, modified Senning-arterial switch procedure was performed in nine patients, 13 patients underwent a modified Senning-Rastelli procedure, and in one patient a combination of modified Senning and aortic translocation (Bex/Nikaidoh) was used. The median age at the corrective operation was 2 years (from 0.3 to 15.7 years)., Results: There was no mortality or heart transplant within the mean follow-up of 3.4 years. Freedom from reintervention was 77% at 5 years. There were no signs of obstruction of the systemic and pulmonary venous tunnels. The function of both ventricles was normal in all patients, even in the four patients who required retraining of the left ventricle. Mild aortic regurgitation was noticed in three patients. Preoperatively detected significant tricuspid regurgitation either disappeared or became trivial after the operation in all the six patients. All patients except two are in sinus rhythm; one patient is pacemaker-dependent preoperatively and one is pacemaker-dependent postoperatively. There were no clinically apparent neurological problems. All patients, but one, are in the New York Heart Association (NYHA) class I., Conclusions: Anatomic correction of corrected transposition of the great arteries can be performed in selected patients without mortality and with acceptable morbidity. The mid-term functional outcome is excellent, resulting in normal ventricular function, even in retrained left ventricles, and minimal incidence of complete heart block. The long-term function of the aortic valve, intraventricular tunnels, conduits, and ventricles requires close surveillance., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The Aristotle score quantifies the complexity involved in congenital heart surgery. It defines surgical performance as complexity score times hospital survival. We studied how expected and observed surgical performance evolved over time., Methods: 2312 main procedures carried out between 2006 and 2010 were analyzed. The Aristotle basic score, corresponding hospital survival and related observed surgical performance were estimated. Expected survival was based on the mortality risks published by O'Brien and coauthors. Observed performance divided by expected performance was called the standardized ratio of performance. This should trend towards a figure above 100%. Survival rates and performance are given with 95% confidence intervals., Results: The mean Aristotle basic score was 7.88 ± 2.68. 51 patients died: observed hospital survival was 97.8 % (97.1 %-98.3%). 115 deaths were anticipated: expected survival was 95.2% (93.5%-96.3%). Observed and expected surgical performance reached 7.71 (7.65-7.75) and 7.49 (7.37-7.59), respectively. Therefore the overall standardized ratio of performance was 102.94%. The ratio increased from 2006 (ratio = 101.60%) to 2009 (103.92%) and was 103.42% in 2010. Performance was high for the repair of congenital corrected transposition of the great arteries and ventricular septal defect (VSD) by atrial switch and Rastelli procedure, the Norwood procedure, repair of truncus arteriosus, aortic arch repair and VSD closure, and the Ross-Konno procedure, with corresponding standardized ratios of 123.30%, 116.83%, 112.99%, 110.86% and 110.38%, respectively. With a ratio of 82.87%, performance was low for repair of Ebstein's anomaly., Conclusion: The standardized ratio of surgical performance integrates three factors into a single value: procedure complexity, postoperative observed survival, and comparison with expected survival. It constitutes an excellent instrument for quality monitoring of congenital heart surgery programs over time. It allows an accurate comparison of surgical performance across institutions with different case mixes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Since the early 1990's, grapefruit juice has been implicated in drug interaction with various furanocoumarins (FCs) now associated with the effect. Although FCs are present in various fruits and vegetables, it is their presence in grapefruit that has attracted the most attention. Studies have shown that FCs in grapefruit juice can vary significantly and from multiple causes. Most of all, FCs are stress-induced molecules, their levels affected by many factors ranging from UV exposure to insect infestation. There are also varietal and seasonal factors. In this study, juice processing and storage parameters were investigated. Prolonged fruit storage prior to processing and most steps involved in juice processing had little influence on the levels of 6',7'-dihydroxybergamottin (DHB), paradisin C, or bergamottin. However, products that were hot filled or stored at room temperature had lower amounts of DHB and paradisin C and higher amounts of bergaptol compared to juices that were not hot filled and stored at refrigerated temperatures. Both DHB and paradisin C are potent CYP3A4 inhibitors, while bergaptol is a very weak inhibitor. Bergamottin amounts decreased to a lesser extent. Therefore, grapefruit juice products that were hot filled or have been stored at room temperature for an extended period of time will have a reduced drug interaction potential., (Journal compilation © 2011 Institute of Food Technologists® No claim to original US government works.)

Objectives: Aristotle score methodology defines surgical performance as 'complexity score times hospital survival'. We analysed how this performance evolved over time and in correlation with case volume., Methods: Aristotle basic and comprehensive complexity scores and corresponding basic and comprehensive surgical performances were determined for primary (main) procedures carried out from 2006 to 2009. Surgical case volume performance described as unit performance was estimated as 'surgical performance times the number of primary procedures'., Results: Basic and comprehensive complexity scores for the whole cohort of procedures (n=1828) were 7.74±2.66 and 9.89±3.91, respectively. With an early survival of 97.5% (1783/1828), mean basic and comprehensive surgical performances reached 7.54±2.54 and 9.64±3.81, respectively. Basic surgical performance varied little over the years: 7.46±2.48 in 2006, 7.43±2.58 in 2007, 7.50±2.76 in 2008 and 7.79±2.54 in 2009. Comprehensive surgical performance decreased from 9.56±3.91 (2006) to 9.22±3.94 (2007), and then to 9.13±3.77 (2008), thereafter increasing up to 10.62±3.67 (2009). No significant change of performance was observed for low comprehensive complexity levels 1-3. Variation concerned level 4 (p=0.048) which involved the majority of procedures (746, or 41% of cases) and level 6 (p<0.0001) which included a few cases (20, or 1%), whereas for level 5, statistical significance was almost attained: p=0.079. With a mean annual number of procedures of 457, mean basic and comprehensive unit performance was estimated at 3447±362 and 4405±577, respectively. Basic unit performance increased year to year from 3036 (2006, 100%) to 3254 (2007, 107.2%), then 3720 (2008, 122.5%), up to 3793 (2009, 124.9%). Comprehensive unit performance also increased: from 3891 (2006, 100%) to 4038 (2007, 103.8%), 4528 (2008, 116.4%) and 5172 (2009, 132.9%)., Conclusions: Aristotle scoring of surgical performance allows quality assessment of surgical management of congenital heart disease over time. The newly defined unit performance appears to well reflect the trend of activity and efficiency of a congenital heart surgery department., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Hospital costs are expected to correlate with clinical complexity. Do costs for congenital heart surgery correlate with Aristotle complexity scores?, Methods: 442 inpatient stays in 2008 were evaluated. Aristotle scores and levels were determined. Costs were estimated according to the German Institute for Hospital Reimbursement system. Pearson and Spearman R correlation coefficients and corresponding goodness-of-fit regression coefficients R2 were calculated., Results: Mean basic and comprehensive Aristotle scores were 7.60 +/- 2.74 and 9.23 +/- 2.94 points, respectively. Mean expenses per hospital stay amounted to 29,369 +/- 30,823 Euros. Aristotle basic and comprehensive scores and levels were positively correlated with hospital costs. With a Spearman R of 1 and related R2 of 0.9436, scores of the 6 Aristotle comprehensive levels correlated best. Mean hospital reimbursement was 26,412 +/- 17,962 Euros. Compensation was higher than expenses for patients in comprehensive levels 1 to 3, but much lower for those in levels 4 to 6., Conclusions: Aristotle comprehensive complexity scores were highly correlated with hospital costs. The Aristotle score could be used as a scale to establish the correct reimbursement after congenital heart surgery., (Georg Thieme Verlag KG Stuttgart, New York.)

Our purpose was to evaluate our single-center experience with the treatment of transposition of the great arteries (TGA) with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO). Between 1992 and 2009, 42 patients were operated on. Twenty-three patients underwent the Rastelli operation, 8 patients underwent arterial switch operation (ASO) with associated LVOTO procedures, 4 patients underwent the réparation à l'étage ventriculaire (REV) procedure, 3 patients underwent the Bex/Nikaidoh (BN) procedure, and the Fontan operation was performed in 4 patients. The median age at final operation was 20.7 months (range, 0.3-234). The overall survival rate was 97% (1 early death), with a median follow-up of 8.2 years. There were no differences in survival among the surgical groups. Event-free survival was 100%, 84%, 59%, and 24% at 1, 5, 10, and 15 years of follow-up, respectively, with it being worse in the Rastelli group (P < .0348). The last echocardiography showed good function of the systemic ventricle in all patients; LVOTO pressure gradient greater than 30 mm Hg was observed in 2 patients (5%), and right ventricular outflow tract obstruction (RVOTO) pressure gradient >30 mm Hg was observed in 12 patients (31%). All patients are in sinus rhythm, and 74% of them are without medication. All surgical approaches are safe and show excellent midterm functional outcome. ASO is the best option if the LVOTO is resectable. Intraventricular rerouting (Rastelli or REV) is the method of choice in the majority of patients, but Rastelli has a significant reintervention rate. The BN operation has the potential to minimize utilization of the Fontan operation, which was used in the past if the intracardiac anatomy was unfavorable.

The aim of this study was to analyze the midterm results following the Ross-Konno procedure in children. Between 1999 and 2008, 29 patients with complex left ventricular outflow tract obstruction underwent the Ross-Konno procedure. There were 12 (41%) infants (group A) and 17 (59%) older patients (group B). The median age at operation was 3.3 years (range, 6 days to 16 years). At 7 years of follow-up, survival was 96% (1 late death), with no differences between groups A and B. Freedom from aortic regurgitation ≥ mild was 81%, with no differences between groups A and B. No residual gradient was noted in the left ventricular outflow tract in either group. Freedom from mitral regurgitation ≥ mild was 100% in group B and 41% in group A (P = .0029). The mitral regurgitation was associated with morphological abnormalities of the mitral valve and with development of endocardial fibroelastosis after failed intervention during the newborn period. Freedom from reoperation was 73% in group B and 24% in group A (P = .0093). All patients are now in sinus rhythm, and 43% are without medication. With the technical aspects of this procedure well accomplished, mortality is low, and the functional outcome is encouraging. At midterm follow-up, there was no residual or recurrent outflow tract obstruction and an excellent function of the neoaortic valve. The higher incidence of mitral regurgitation in infants, which was associated with morphological abnormalities of mitral valve and development of endocardial fibroelastosis, is worrisome.

Background: Stage I palliation of hypoplastic left heart syndrome (HLHS) and its variants is usually performed by a Norwood operation. The management of pulmonary blood flow during this procedure remains controversial. The RV-to-PA conduit (RVPAC) has been proposed as the better alternative compared to a systemic-to-pulmonary shunt (SPS)., Methods: A retrospective single center chart review of consecutive patients who underwent a Norwood I procedure between 01/1997 and 09/2006 was performed. All patients were operated in deep hypothermia, with or without circulatory arrest, using different shunt modifications according to surgeon's preference. Patients were divided into two groups depending on surgical management for pulmonary blood flow (modified BT shunt [BT] and non-valved RVPAC [Sano])., Results: Fifty-four patients were included in the study (BT: 31 patients vs. Sano: 23 patients). Diastolic blood pressure during the first 24 hours postoperatively was significantly lower in the BT group (BT: 38.6 +/- 6.9 mmHg vs. Sano: 42.4 +/- 7.2 mmHg; P < 0.01) with a trend towards a higher systolic blood pressure (BT: 74.1 +/- 13.5 mmHg vs. Sano: 69.8 +/- 12.1 mmHg; P = 0.08). Mean circulatory arrest time in the BT group was significantly longer compared to the Sano patients (BT: 41 +/- 21 min vs. Sano: 25 +/- 23 min; P < 0.01). The mean hospital stay was 18.5 days for BT patients and 20 days for Sano patients ( P = 0.45). Early mortality for the total cohort was 14.8 % (n = 8) (BT 19.4 % [n = 6] vs. Sano 8.7 % [n = 2]; P = 0.12). There was no significant difference in inter-stage mortality between the two groups (BT: 18.2 % vs. Sano: 21.1 %; P = 0.47)., Conclusion: The results for both established surgical methods (BT and Sano) for the palliation of HLHS and its variants have improved over time and are reaching acceptable early mortality rates. There was a trend towards a favorable early outcome for Sano patients, which did not reach statistical significance in this study due to the low patient numbers.

Pulmonary artery sling (PAS) is a rare congenital heart disease in which the left pulmonary artery (LPA) originates from the right pulmonary artery (RPA) and encircles the distal trachea and right mainstem bronchus as it courses between the trachea and esophagus. Typically, patients with PAS have some respiratory symptoms, either due to external tracheal compression that can be corrected by relief of the sling mechanism, or due to severe diffuse tracheal stenosis with complete rings (ring-sling complex). The diagnosis of PAS is optimally made by echocardiography, while bronchoscopy is the key to the assessment of tracheal stenosis. Diagnosis is indication for surgery. Repair using a strategy of median sternotomy, cardiopulmonary bypass, division of the LPA and reimplantation into the main pulmonary artery (MPA), and simultaneous tracheal repair takes preference. Tracheal repair should be considered only in clinically symptomatic patients. The techniques of free tracheal autograft plasty or slide tracheoplasty offer promising results, and the choice of tracheal reconstruction should be guided by the clinical experience of the surgeon. Coexisting intracardiac pathologies are repaired at the same time. Postoperative care requires close multidisciplinary effort to achieve the best long-term result.

Grapefruit (Citrus paradisi Macf.) furanocoumarins and related compounds have been shown to interact with the enterocyte cytochrome P450, CYP3A4, and as a result they affect the bioavailibility of certain drugs. Only a few grapefruit furanocoumarins have been identified so far. In this study, grapefruit juice retentate, rich in furanocoumarins, was extracted and then separated by flash chromatography for the examination of new compounds. Finally, nine new furanocoumarins were detected in different fractions according to their UV spectra and mass spectrometric properties by LC-MS (liquid chromatography mass spectrometry) and tentatively designated as FC 338, FC 420, FC 524, FC 530, FC 540, FC 546, FC 552, FC 570 and FC 614.

Controversy persists regarding the management of patients suffering from tetralogy of Fallot with absent pulmonary valve syndrome. Airway obstruction caused by the dilated pulmonary arteries is the determining factor in the mortality of symptomatic newborns and infants. A number of surgical techniques for the reduction of bronchial obstruction have been proposed, producing variable results. All strategies have focused on plication and reduction of the anterior or posterior wall of the normally positioned pulmonary arteries, with or without pulmonary valve replacement. An alternative approach is to bring the pulmonary arteries anterior to the aorta and away from the trachea and bronchial tree. This technique has the potential to reduce or eliminate bronchial compression by the central pulmonary arteries. Failure of the treatment could be expected in symptomatic patients, where the pathology of the airways extends beyond the proximal pulmonary arteries.

Objective: Neonatal primary repair has progressively become the treatment of choice for truncus arteriosus with encouraging survival. However, use of valved conduits to reconstruct the right ventricular outflow tract (RVOT) inevitably induces reintervention. This study estimates survival and rate of catheter-interventional and surgical reinterventions., Methods: Thirty-five consecutive neonates who underwent truncus repair with 27 homografts and 8 Contegras from 1987 to 2007 were studied. Interrupted aortic arch (IAA) was associated in nine patients. Actuarial survival and freedom from reintervention were evaluated according to Kaplan-Meier method., Results: Five patients died early after repair. Two died late and one death was related to reintervention. Survival was 91.9%+/-5.4% from postoperative month 2 onwards when IAA was not associated and 41.7%+/-17.3% from month 4 in IAA presence. During a median follow-up of 68 months (range 1-180 months), 42 reinterventions (of which 17 reoperations) were performed in 21 patients. Rate of reintervention was 2.6 per early survivor per 10 years. RVOT obstruction constituted the main indication: branch pulmonary arteries often being involved (n=25). Uncommon indication was subaortic stenosis (n=3), aortic arch obstruction (n=2) and truncal valve regurgitation (n=2). At year 10, freedom from first, second and third reintervention was 17.9 %+/-8.1%, 46.1%+/-10.6% and 81.9%+/-9.5%, respectively. Sixteen first conduits were explanted. Freedom from first conduit replacement was 87.5%+/-6.8%, 64.1%+/-10.2% and 39.5%+/-10.7% at year 1, 3 and 5, respectively. Homografts enjoyed higher durability than Contegras., Conclusion: Neonatal repair of truncus arteriosus results in high survival, the only risk being IAA association. The rate of reintervention is heavily influenced by stenosis of branch pulmonary arteries.

Objective: The policy of early repair of patients with tetralogy of Fallot, irrespective of age, as opposed to initial palliation with a shunt, remains controversial. The aim of our study was to analyze the midterm outcome of primary early correction of tetralogy of Fallot., Methods: Between 1996 and 2005, a total of 61 consecutive patients less than 6 months of age underwent primary correction of tetralogy of Fallot in two institutions. The median age at surgery was 3.3 months, and 27 patients (44%) were younger than 3 months of age, including 12 (20%) newborns. We analyzed the patients in 2 groups: those younger than 3 months of age, and those aged between 3 and 6 months., Results: There was one early (1.6%), and one late death. Actuarial survival was 98.4%, 96.7%, 96.7% at 1, 5, and 10 years respectively, with a median follow up of 4.5 years. There was no difference in survival, bypass time, lengths of ventilation, and hospital stay between the groups. A transjunctional patch was placed significantly more often in the patients younger than 3 months (p = 0.039), with no adverse effect on survival and morbidity during the follow-up. Freedom from reoperation was 98.2%, 92.2%, and 83% at 1, 5, and 10 years respectively, with no difference between the groups., Conclusion: Elective primary repair of tetralogy of Fallot in asymptomatic patients is delayed beyond 3 months of age. In symptomatic patients, primary repair of tetralogy of Fallot is performed irrespective of age, weight and preoperative state. This approach is safe, and provides an excellent midterm outcome with acceptable morbidity and rates of reintervention. The long-term benefits of this approach must be established by careful follow-up, with particular emphasis on arrhythmias, right ventricular function, and exercise performance.

A biomechanical musculo-skeletal model of functional electrical stimulation (FES)-induced rat ankle motion was implemented and tested in rat experiments. The muscle model is a new Hill-based model which includes established physiological relations of force-velocity and force-length-frequency. However, the series-elastic component and the activation component of previous Hill-based models are replaced by a new component which accounts for dynamic time delays and recruitment that occur in real muscle force generation during limb movements. The skeletal model includes gravity and dynamic forces that occur in real rat ankle motions. In computer simulations, various FES patterns were applied to the tibialis anterior (TA) and soleus (SO) model muscles to produce walk-like ankle motions. In lab experiments, the same stimulation patterns were applied by epimysial electrodes implanted in the TA and SO muscles of live rats cordotomized at level T7. The resulting rat motions were recorded by video camera. Video data was converted to ankle angle-vs-time files for comparison with corresponding model angle-vs-time files. Over a physiologically significant range of ankle motions, model parameters were adjustable to yield model motions that agreed with rat motions to within 2 degrees (root mean square differences of rat and model ankle angles). This is shown in plots of model and rat motions presented here for representative cases of FES. The accuracy of our model in reproducing real ankle motions supports the hypothesis that our new muscle model generates correct muscle forces over a useful range of limb motions. It suggests that the model may be useful in the design of FES neural prostheses.

We report a case of aortic perforation after transcatheter closure of an atrial septal defect by an Amplatzer septal occluder. During emergency surgery, perforations of the dome of the right atrium and the noncoronary sinus of Valsalva of the aorta were repaired. Atrial septal defect was primarily closed. A short anterosuperior rim should be considered a risk factor for aortic perforation in transcatheter atrial septal defect closure.

Background: The STS-EACTS International Nomenclature for Congenital Heart Surgery (CHS) defines four anatomic subtypes of double outlet right ventricle (DORV) based on the relationship of the ventricular septal defect (VSD) with the great vessels and the presence of right ventricular outflow tract obstruction (RVOTO). We reviewed our experience with DORV patients and two ventricles that underwent repair, applying this nomenclature., Methods: Between January 2000 and January 2005, 50 patients with DORV and two viable ventricles underwent surgical intervention: 44 patients had biventricular repair, 3 had 1.5 ventricular repair, 2 underwent a Fontan, and 1 died prior to corrective surgery. Median age at repair was 9.1 months (range: 4D-4Y). Eighteen patients (36%) were DORV-Fallot (including 5 with AVSD and heterotaxy), 9 (18%) were DORV-TGA (Taussig-Bing), 12 (24%) were DORV-VSD, and 11 (22%) were DORV non-committed VSD. Corrective surgery included 35 repairs with a VSD-aorta baffle+/-RVOTO procedure and 12 arterial switches with a VSD-PA baffle (9 Taussig-Bing and 3 DORV-ncVSD). Associated procedures included 13 VSD enlargements, 8 subaortic resections, 9 arch repairs, 5 AVSD repairs, and 7 others., Results: There were three deaths in the 50 patients studied (overall mortality of 6%). Excluding one patient that died prior to corrective surgery and the two patients palliated with a Fontan procedure, the actual surgical mortality for a corrective repair was 4.3% (2/47 patients). Two surgical deaths occurred following, respectively, one repair of a Taussig-Bing with an interrupted arch and a Swiss cheese VSD and one repair of ncVSD-type with pulmonary atresia that had undergone a previous cavo-pulmonary anastamosis. No late deaths occurred. Two late reoperations included a heart transplant in a DORV-Fallot patient with Swiss cheese VSD and subaortic resection in a DORV-ncVSD patient. Angioplasties were needed for PA stenosis (n=2) and aortic arch obstruction (n=2). Four patients had LV to aorta baffle gradients between 10 and 20 mmHg. All patients were of NYHA class I/II., Conclusions: The STS-EACTS International Nomenclature provides more uniform analysis of outcomes with respect to acceptable surgical risk and mortality. Biventricular repair can be safely achieved on selected DORV, including DORV-ncVSD and DORV with AVSD and heterotaxy lesions traditionally indicated for a single ventricle palliative approach.

We conducted a prospective study in a pediatric cardiac intensive care unit in order to determine the diagnostic value of N-terminal brain natriuretic peptide (N-BNP) plasma concentration in the perioperative care of children with congenital heart disease (CHD). N-BNP plasma concentrations were determined by using a validated enzyme immunoassay. We measured N-BNP the day before surgery and up to 15 days postoperatively in 23 children (age range, 0.25-11 years) undergoing cardiac surgery due to various CHDs. Supply and duration of catecholamines, vasodilators, and respiratory therapy were determined and correlated to N-BNP. In addition, troponin T (TnT) and arterial Lactat (aL) concentrations were measured simultaneously. We found a significant correlation between preoperative and maximal N-BNP levels and dosage of vasodilators (r = 0.41, p < 0.02 and r = 0.83, p < 0.01, respectively). Maximal TnT and aL levels were not correlated to dosage of vasodilators. The dosage and duration of catecholamines, the duration of respiratory therapy, and the plasma concentration of TnT and aL were not correlated to pre- or perioperative N-BNP. Maximal TnT and aL levels were correlated to duration (r = 0.53, p < 0.01 and r = 0.48, p < 0.02) and dosage (r = 0.52, p < 0.02 and r = 0.60, p < 0.01) of catecholamines and duration of respiratory therapy (r = 0.57, p < 0.01 and r = 0.50, p < 0.02). As recent studies show, N-BNP appears to be a powerful neurohumoral indicator of ventricular function and prognosis for guiding therapy in the outpatient department or for discriminating cardiac from noncardiac symptoms. In contrast, the value of N-BNP for guiding perioperative therapy in pediatric cardiac intensive care units is limited.

The Ross-Konno procedure, applied to neonates with severe left ventricular outflow tract (LVOT) obstruction, offers a satisfactory solution in fully releasing the LVOT gradient, and in replacing the aortic valve with a pulmonary autograft with an excellent growth potential. We reported on three recent neonatal cases.

Objectives: Biventricular repair of double outlet right ventricle non-committed ventricular septal defect (DORVncVSD) is usually achieved by a VSD rerouting to the aorta. This technique can be limited by the presence of tricuspid chordae and by the pulmonary artery to tricuspid valve distance. Furthermore, there is an important risk of late subaortic obstruction related to the long patch required that creates a potential akinetic septal area. Presented here is another technique; by VSD rerouting to the pulmonary infundibulum and arterial switch., Methods: Ten patients, with DORVncVSD, underwent a VSD rerouting to the pulmonary infundibulum followed by arterial switch. Seven had a previous pulmonary artery banding and one a moderate infundibular stenosis. The median age at surgery was 16 months (range 3 weeks to 4.5 years). All patients had a bilateral infundibulum, with a large persistent subaortic conus, D malposition of the aorta, side-by-side vessels and double loop coronary patterns. The VSD was perimembranous with inlet or trabecular extension. Subaortic obstruction was constant. The VSD was severely distant from both the aortic and the pulmonary annulus. The operation was conducted through a combined approach. The VSD was constantly enlarged superiorly. The almost permanent subaortic obstruction was released. The VSD was always found quite close to the pulmonary infundibular ostium. The arterial switch technique was adapted to the complex coronary anatomy., Results: There was one non-cardiac death. At a mean follow-up of 20 months, all nine survivors are in NYHA class I, in sinus rhythm, and have no subaortic gradient greater than 15 mm., Conclusion: This technique of VSD rerouting to the pulmonary artery and arterial switch limits greatly the size of the rerouting patch, respects the tricuspid chordae and is independent of the pulmonary artery-tricuspid valve distance. In this early series of biventricular repair of DORVncVSD, the VSDs were always found close to the pulmonary artery, allowing this new type of repair.

Gene expression in the Caenorhabditis elegans pharynx is regulated in part by organ-specific signals, which in the myo-2 gene target a regulatory sequence called the C sub-element. C sub-element activity requires the organ specification factor PHA-4, a winged-helix transcription factor expressed in all pharyngeal cells. To identify additional factors involved in pharyngeal organogenesis, we performed a yeast one-hybrid screen for C sub-element binding proteins. Here we describe the novel factor PEB-1, which is coexpressed with PHA-4 in many pharyngeal cell types, including muscles, epithelial cells, marginal cells, and glands, but is undetectable in the pharyngeal nervous system. PEB-1 is also detected outside the pharynx in cells surrounding the rectum and vulva, as well as in the germ line. Reduction of peb-1 function using RNAi results in morphological defects in the somatic tissues in which peb-1 is expressed. We have mapped the PEB-1 DNA-binding domain to a 158-residue region, which is unrelated to known DNA-binding proteins but shares some sequence similarity to the Drosophila Mod(mdg4) proteins. PEB-1 specifically recognizes a site in the C subelement that partially overlaps the PHA-4 binding site. Both the PEB-1 and the PHA-4 binding sites are necessary for strong C sub-element enhancer activity in some cells in which these factors are coexpressed. In contrast the PEB-1 site is dispensable for C sub-element activity in pharyngeal neurons. We propose that PEB-1 functions with PHA-4 to activate target gene expression in cells in which they are coexpressed.

Nosocomial Infections caused by vancomycin-resistant enterococci (VRE) are an emerging threat to critically ill patients. At the University Hospital Eppendorf, VRE were isolated from 38 patients between August 1993 and April 1997, of whom 32 were hospitalized at the Department of Pediatrics. Pulsed-field gel electrophoresis revealed that 26 Enterococcus faecium isolates from patients of the Department of Pediatrics were identical or closely related, and that isolates from three additional patients of the same department were possibly related. All of these isolates were of vanA genotype. They were resistant to glycopeptides, ampicillin, ciprofloxacin, clindamycin, and erythromycin. Most isolates displayed high-level resistance to gentamicin, but all remained susceptible to quinupristin/dalfopristin. Implementation of stringent hand disinfection and environmental disinfection policies, as well as measures for patient isolation contained this first outbreak of VRE at a German Children's hospital, which emphasizes the importance of hygienic measures for the control of nosocomial spread of these organisms.

Gene expression in the pharyngeal muscles of Caenorhabditis elegans is controlled in part by organ-specific signals, which in the myo-2 gene target a short DNA sequence termed the C subelement. To identify genes contributing to these signals, we performed a yeast one-hybrid screen for cDNAs encoding factors that bind the C subelement. One clone recovered was from daf-3, which encodes a Smad most closely related to vertebrate Smad4. We demonstrated that DAF-3 binds C subelement DNA directly and specifically using gel mobility shift and DNase1 protection assays. Mutation of any base in the sequence GTCTG interfered with binding in the gel mobility shift assay, demonstrating that this pentanucleotide is a core recognition sequence for DAF-3 binding. daf-3 is known to promote formation of dauer larvae and this activity is negatively regulated by TGFbeta-like signaling. To determine how daf-3 affects C subelement enhancer activity in vivo, we examined expression a gfp reporter controlled by a concatenated C subelement oligonucleotide in daf-3 mutants and other mutants affecting the TGFbeta-like signaling pathway controlling dauer formation. Our results demonstrate that wild-type daf-3 can repress C subelement enhancer activity during larval development and, like its dauer-promoting activity, daf-3's repressor activity is negatively regulated by TGFbeta-like signaling. We have examined expression of this gfp reporter in dauer larvae and have observed no daf-3-dependent repression of C activity. These results suggest daf-3 directly regulates pharyngeal gene expression during non-dauer development.

Development of pharyngeal muscle in nematodes and cardiac muscle in vertebrates and insects involves the related homeobox genes ceh-22, nkx2.5, and tinman, respectively. To determine whether the nematode and vertebrate genes perform similar functions, we examined activity of the zebrafish nkx2.5 gene in transgenic Caenorhabditis elegans. Here, we report that ectopic expression of nkx2.5 in C. elegans body wall muscle can directly activate expression of both the endogenous myo-2 gene, a ceh-22 target normally expressed only in pharyngeal muscle, and a synthetic reporter construct controlled by a multimerized CEH-22 binding site. nkx2.5 also efficiently rescues a ceh-22 mutant when expressed in pharyngeal muscle. Together, these results indicate that nkx2.5 and ceh-22 provide a single conserved molecular function. Further, they suggest that an evolutionarily conserved mechanism underlies heart development in vertebrates and insects and pharyngeal development in nematodes.

Pharyngeal muscle development in the nematode Caenorhabditis elegans appears to share similarities with cardiac muscle development in other species. We have previously described CEH-22, an NK-2 class homeodomain transcription factor similar to Drosophila tinman and vertebrate Nkx2-5, which is expressed exclusively in the pharyngeal muscles. In vitro, CEH-22 binds the enhancer from myo-2, a pharyngeal muscle-specific myosin heavy chain gene. In this paper, we examine the role CEH-22 plays in pharyngeal muscle development and gene activation by (a) ectopically expressing ceh-22 in transgenic C. elegans and (b) examining the phenotype of a ceh-22 loss-of-function mutant. These experiments indicate that CEH-22 is an activator of myo-2 expression and that it is required for normal pharyngeal muscle development. However, ceh-22 is necessary for neither formation of the pharyngeal muscles, nor for myo-2 expression. Our data suggest parallel and potentially compensating pathways contribute to pharyngeal muscle differentiation. We also examine the relationship between ceh-22 and the pharyngeal organ-specific differentiation gene pha-1. Mutations in ceh-22 and pha-1 have strongly synergistic effects on pharyngeal muscle gene expression; in addition, a pha-1 mutation enhances the lethal phenotype caused by a mutation in ceh-22. Wild-type pha-1 is not required for the onset of ceh-22 expression but it appears necessary for maintained expression of ceh-22.

Thirty people with classical or definite rheumatoid arthritis received laser exposure to a Q-switch neodymium laser that operated at 1.06 micrometer with an output of 15 joules/cm2 for 30 nsec. One hand was lased at the proximal interphalangeal (PIP) and metacarpal phalangeal (MCP) joints, whereas the other hand was sham lased. The patient, physician, and occupational therapy evaluators did not know which hand was being lased. Twenty-one patients noted improvement of both their MCP and PIP joints of both hands during laser therapy. Twenty-seven noted improvement of their PIP joints and 26 noted improvement of the MCP joints during therapy. Heat, erythema, pain, swelling, and tenderness all improved with time in both hands, but the lased hand had more significant improvement in erythema and pain. There was also significant improvement in grasp and tip pressure on the lased side. The level of circulating immune complexes as measured by platelet aggregation decreased during lasing. The improvement may be related to laser exposure. The exact role that laser radiation has upon rheumatoid arthritis and its mechanism of action remain to be elucidated.

In 21 patients with nonresected stomachs and symptoms of delayed gastric emptying, obstruction was excluded by upper gastrointestinal series and upper endoscopy; all had abnormal results of barium test meal (BTM) study. Each had repeat BTM after the administration of 10 mg of metoclopramide. Each patient also had two gamma camera studies after a technetium Tc 99m sulfur colloid labeled meal; normal saline or metoclopramide was administered before each test in a blinded and random manner. Half-time (T1/2) and percentage of isotope remaining at six hours (GC6) were recorded. Ten asymptomatic controls had a gamma camera scanning study, and seven of these had a BTM. Nine of 19 patients had a T1/2 in the normal range, and in 12 of 19 patients the GC6 was in the normal range. The magnitude of retention of barium at six hours on the BTM did not correlate with the T1/2 (r = 0.076) or the GC6 (r= 0.296). Thus, these tests were not comparable in this study. By regression analysis, a significant reduction was shown in the amount of retained food and barium (P less than .01), the T1/2 (P less than .01), and the GC6 (P less than .01) after intramuscular administration of metoclopramide, indicating that both tests were able to evaluate the effects of this drug.

Acute calcific quadriceps tendinitis can be the cause of acute periarthritis of the knee. Physical examination can detect cellulitis and a tender tendon sheath. Lateral roentgenograms of soft tissues show thickening of the tendon and sometimes small flecks of amorphous calcification within the body of the tendon near the attachment. Although hyperostosis of the patella near the tendon attachment is often present, it is well defined ossification and not associated with the acute symptoms. The amorphous calcium deposits quickly disappear during the acute tendinitis and are not detected on follow-up radiologic examination.

The posteromedial aspect of the distal end of the femur in the area of insertion of the adductor magnus is the site of occurrence of a developmental defect that may have the roentgenographic characteristics of a malignant bone tumor. As it is asymptomatic, this common defect is almost always an incidental finding, but it has been confused with osteosarcoma. The lesion is thought to be due to trauma or the avulsion of small bits of bone at the site of insertion of the adductor magnus muscle. Histologically the lesion has been mistaken for osteosarcoma because of the immature reactive bone and fibrous tissue presnet. It is usually possible to identify these defects roentgenographically and avoid biopsy.