"Not such a kid thing anymore": Young adults' perspectives on transfer from paediatric to adult cardiology care.

BACKGROUND: Transfer of adolescents with congenital heart disease from paediatric cardiology providers to specialized adult congenital heart disease (ACHD) care providers is becoming a standard practice. However, some paediatric cardiologists continue to provide care for their patients into adult life. Little is known about the perspectives of young adult patients who have been transferred to ACHD clinics versus those who continue to receive their cardiology care in paediatric settings. METHODS: Content and thematic analysis of structured telephone interviews with 21 young adults age 18-25 (13 transferred to ACHD clinic and 8 who had not transferred) was conducted to identify similarities and differences in patient characteristics of those in ACHD versus paediatric settings. RESULTS: There were no appreciable differences in gender, age, heart disease type, and independence between those transferred to ACHD care versus those not transferred. Participants in both groups were aware of differences between the paediatric and ACHD care settings and providers, with some favouring the familiarity offered by the paediatric setting and providers. Participants had varying views on parental involvement in their care; most of them had attended clinic appointments on their own. Those who had transferred to ACHD care acknowledged that it would take time to adjust to new relationships. Positive perspectives on actual or anticipated transfer to ACHD care included a growing sense of autonomy and responsibility, as well as access to reproductive information relevant to ACHD patients. CONCLUSIONS: The absence of patient characteristics distinguishing those in ACHD care versus those still followed in paediatric care suggests that system, provider, and parent factors, rather than patient factors, may account for patients' perspectives on transfer to ACHD care.

Active retinitis in an infant with postnatally acquired cytomegalovirus infection.

Congenital cytomegalovirus (CMV) is frequently associated with active retinitis. In contrast, in the immunocompetent neonate with postnatally acquired CMV infection retinitis is rarely present and usually does not progress. We describe the case of an infant with postnatal CMV infection and active retinitis diagnosed at 20 days of life. Owing to the rapid progression of the retinitis, therapy with intravenous ganciclovir was performed, with prompt regression of the retinitis. Therapy was then continued with oral valganciclovir for one further week. Although very unusual, CMV retinitis has to be taken into consideration in neonates with early postnatally acquired CMV infection, as an early diagnosis and treatment may be crucial to avoid visual impairment.

Ten-year follow-up after pediatric transplantation.

From November 1985 through December 1996, 128 patients aged 1 day to 18 years (mean age, 4.7 yrs; median, 3 years) were listed for heart transplant. Forty-seven (36.1%) died after a mean wait of 3.1 months, and 62 underwent transplant after a mean wait of 4 months. Two patients underwent retransplantation. The 1-, 5-, and 11-year actuarial survival rate for the patients who underwent heart transplantation is 68%, 62%, and 42%, respectively. The follow-up ranges from O to 132 months, with a mean follow-up of 39 months. At present, 36 patients, including the 2 who received a retransplant, are alive. Most of them have normal growth, development, and neurologic outcome.

IL-8, IL-6 and ICAM-1 in serum of paediatric patients undergoing cardiopulmonary bypass with and without cardiocirculatory arrest.

BACKGROUND: The aim of the present study was to evaluate the systemic inflammatory response to CPB in paediatric patients undergoing surgical correction of congenital heart diseases. EXPERIMENTAL DESIGN: comparative investigation. SETTING: paediatric cardiology hospital INTERVENTION: ICAM-1, IL-8, and IL-6 production were analysed before and during CPB, and after surgery in 9 paediatric patients, submitted to cardiocirculatory arrest (Group A); and in 11 without cardiocirculatory arrest (Group B). MEASURES: ICAM-1, IL-8, and IL-6 production were analysed from arterial samples before and during CPB, and after surgery. RESULTS: In group A vs group B a significant increase of IL-8 was detected during (297+/-250 vs 11+/-19 pg x ml(-1), p<0.001) and after (100+/-230 vs n.d. pg x ml(-1)) surgery and was correlated with the duration of operation (r=0.759; p=0.0001) and clamping time (r=0.738; p<0.05). After surgery in group A, IL-6 levels (35+/-43 pg x ml) were higher than those in group B (2+/-5 pg x ml), and a good correlation was observed between IL-6 and duration of aortic clamping (r=0.714; p=0.048), cardiac arrest, (r=0.714; p=0.048), and length of surgery (r=0.867; p=0.04). CONCLUSIONS: In children who underwent CPB with cardiocirculatory arrest cytokine production seems related to duration of operation and amplified by ischemia-reperfusion phenomena.

[Unreliability of pulse oximetry in hypothermic children after cardiovascular surgery with deep hypothermic circulation]. / Inattendibilità del pulse oximetry in lattanti ipotermici dopo interventi di cardiochirurgia in ipotermia profonda.

BACKGROUND: The aim of the study was to evaluate the accuracy of oxygen saturation with the pulse oximeter (SpO2) in children undergoing cardiovascular surgery with deep hypothermic circulation. METHODS: The SpO2 values measured at the hand and at the foot were compared in 50 patients with the arterial oxygen saturation (SaO2) measured with the oximeter. A variance value between the two measurements less than 3% was considered as a reliable measurement, and the precision of the measurement was defined as the standard deviation of the variability. RESULTS: For skin temperature between 35 and 28 C grade, and for core temperature more than 34 grade, the SpO2 is a reliable measurement of the SaO2; for skin temperature less than 28 grade and core temperature less than 34 grade the SpO2 do not correspond the SaO2. CONCLUSIONS: The variability and the precision of the measurements are not affected the position of the probe (hand or foot).

Total repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: an integrated approach.

OBJECTIVE: Predicting postrepair right ventricular/left ventricular pressure ratio has prognostic relevance for patients undergoing total repair of pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. To this purpose, we currently rely on 2 novel parameters: (1) preoperative total neopulmonary arterial index and (2) mean pulmonary artery pressure changes during an intraoperative flow study. METHODS: Since January 1994, 15 consecutive patients (aged 64 +/- 54 months) with pulmonary atresia, ventricular septal defect, and major aortopulmonary collaterals were managed according to total neopulmonary arterial index. Seven patients with hypoplastic pulmonary arteries and a total neopulmonary arterial index less than 150 mm(2)/m(2) underwent palliative right ventricular outflow tract reconstruction followed by secondary 1-stage unifocalization and ventricular septal defect closure. The other 8 patients with a preoperative index of more than 150 mm(2)/m(2) underwent primary single-stage unifocalization and repair. The ventricular septal defect was closed in all cases (reopened in 1). In 9, such decision was based on an intraoperative flow study. RESULTS: Patients treated by right ventricular outflow tract reconstruction had a significant increase of pulmonary artery index (P=.006) within 22 +/- 6 months. Repair was successful in 14 cases (postrepair right ventricular/left ventricular pressure ratio = 0.47 +/- 0.1). One hospital death occurred as a result of pulmonary vascular obstructive disease, despite a reassuring intraoperative flow study. Accuracy of this test in predicting the postrepair mean pulmonary artery pressure was 89% (95% CI: 51%-99%). At follow-up (18 +/- 12 months), all patients are free of symptoms, requiring no medications. CONCLUSIONS: The integrated approach to total repair of pulmonary atresia, ventricular septal defect, and major aortopulmonary collaterals by preoperative calculation of total neopulmonary arterial index, right ventricular outflow tract reconstruction (when required), and intraoperative flow study may lead to optimal intermediate results.

[Use of mesoglycan in venous pathology]. / Uso del mesoglicano in patologia venosa.

Twenty-five female patients suffering from primary venous insufficiency of the lower limbs underwent parenteral and oral treatment with mesoglycan for 3 months. In addition to an evaluation of the subjective and objective parameters linked to venous insufficiency, all patients underwent lower limb venous echo colour-Doppler and videocapillaroscopy using an optic probe in a perimalleolar or periulcerous site. At the end of treatment, all patients reported an improvement in subjective parameters, which was confirmed by a reduction of distal edema in 22 out of 25 cases. There was also an improvement in capillaroscopic findings (reduction of edema of pericapillary connective tissue, reduction of capillary and venular ectasia.

[Diaphragm paralysis following pediatric heart surgery. Review of 25 treated cases]. / La paralisi del diaframma dopo cardiochirurgia pediatrica. Revisione di 25 casi trattati.

Postoperative diaphragm paralysis after pediatric heart surgery is the cause of respiratory insufficiency for which there is currently no agreed treatment. The two hypotheses now considered are: early folding of the diaphragm or longterm assisted ventilation. A retrospective study from 1988 to January 1995 on the incidence of diaphragm paralysis and the type of treatment performed was carried out by the Department of Pediatric Heart Surgery of the Bambino Gesù Hospital in Rome. A total of 25 patients presented diaphragm paralysis out of 3400 operations performed and the clinical records of these patients in intensive care were reexamined. The patients were aged between 2 days and 5 years (mean 3 years) and weighed between 3 kg and 15 kg (mean 6.5). The diagnosis of diaphragm paralysis was made using fluoroscopy of the pulmonary fields during spontaneous breathing; 13 patients were extubated 7 days after diagnosis, 12 underwent surgical folding and were extubated immediately after surgery. The authors underline the particular intolerance to ventilatory insufficiency of pediatric patients after the correction of congenital cardiopathies and the need for early intervention to shorten the stay in intensive care and to avoid the onset of other severe complications such as infection. In particular, in patients undergoing Glenn's or Fontan's modified operation, the integrity of the ventilatory apparatus is essential for the correct function of the new hemodynamic status.

[Post-thoracotomy analgesia in pediatric heart surgery: comparison of 2 different techniques]. / Analgesia post-toracotomia in cardiochirurgia pediatrica: confronto tra due differenti techniche.

The aim of this study was to compare two different post-operative pain control techniques in pediatric patients undergoing thoracotomy with reference to a control group receiving conventional treatment in the form of endovenous morphine. The post-operative antalgic treatment protocol included the random distribution of patients to three groups: control group: endovenous analgesia with morphine boluses; group 1: intrapleural analgesia with bupivacaine boluses; group 2: caudal epidural analgesia in a single bolus with a mix of bupivacaine and morphine. In the comparison it was seen that the method that offered the most effective pain control and fewest collateral effects was caudal peridural analgesia. The authors conclude by suggesting the use of this method and underlining the need to pay greater attention to the problem of postoperative pain in pediatrics.

Peripheral blood stem cells in children with solid tumors. Part I. Feasibility and application.

A method for collecting peripheral blood mononuclear cells following mobilizing chemotherapy in pediatric patients is described. The critical elements of the method included temporary heparinization of the patient to reduce citrate overload, and limiting extracorporeal circulation to 15% of the patient's blood volume using packed red blood cells and albumin. A median of 0.9 x 10(8) mononuclear cells/kg per collection were harvested in 40 collections from eight patients with only one episode of fever and chills. Peripheral blood stem cells were reinfused into six of these patients with refractory/recurrent pediatric tumors after intensive chemotherapy. Bone marrow reconstitution followed with a mean of 30 days (19-38) for absolute neutrophils and 48 days (32-275+) for platelets. Previous chemotherapy did not appear to affect peripheral blood stem cell efficacy in reconstituting chemotherapy-ablated bone marrow.