Cardiopulmonary function in adult patients late after Fontan repair.

OBJECTIVES: The clinical status and exercise assessment of adult patients late after the Fontan operation were reviewed to determine cardiovascular function. BACKGROUND: The Fontan operation is the final operation for many patients with tricuspid atresia or a single ventricle. Follow-up reports describe most patients to be in Canadian Cardiovascular Society functional class I or II. Objective measures of cardiac performance in the pediatric age group have shown significant dysfunction. METHODS: Forty-seven adult patients were seen late after the Fontan operation at the Toronto Congenital Cardiac Centre for Adults. Thirty of these underwent cycle ergometry to determine maximal exercise capacity. Maximal ventilation, maximal oxygen uptake and anaerobic threshold were determined from a ramp exercise protocol. Ejection fraction at rest and during exercise was measured with gated radionuclide angiography. Results were compared with those of eight normal volunteers. Results are given as mean +/- SD. RESULTS: Thirty patients underwent cardiopulmonary exercise testing 6.7 +/- 3.9 years after a first Fontan operation. Clinically 93% were in functional class I or II. The Fontan group patients had a significantly lower maximal work load (548 +/- 171 vs. 1,094 +/- 190 kilopond-meters, p < 0.00001), anaerobic threshold (11.2 +/- 2.9 vs. 23.6 +/- 4.6 ml/kg per min) and maximal oxygen consumption (14.8 +/- 4.5 vs. 42.1 +/- 10.0 ml/kg per min). Systemic ventricular ejection fraction was lower at rest (38 +/- 12% vs. 58 +/- 7%) and during exercise (40 +/- 15% vs. 70 +/- 8%). CONCLUSIONS: Despite a clinical impression of good function, by objective measures adult patients continue to have significant cardiovascular limitation late after the Fontan operation.

Accuracy of home blood glucose monitors.

OBJECTIVE: To determine the accuracy of five home blood glucose monitors (HBGM) in reference to a standard laboratory reference method. RESEARCH DESIGN AND METHODS: The study took place in the laboratory of a 350-bed private acute-care hospital. Subjects were a sample of convenience of 207 diabetic and nondiabetic adult and pediatric patients scheduled for fasting blood work that included a blood glucose test. Venous blood samples were collected for laboratory determination of blood glucose level. A separate sample was collected for testing on two each of five HBGMs: AccuChek II M, Tracer II, ExacTech, Glucometer II with Memory, and One Touch. RESULTS: Multiple regression analysis showed that all 10 monitors could be used to predict laboratory blood glucose values. The monitors with the highest predictabilities were One Touch, Tracer II, and AccuChek II M. Consistency between monitors of the same brand was lowest with One Touch. AccuChek II M had the smallest SD between the 2 monitors used in the study. CONCLUSIONS: HBGM can be used to predict actual laboratory values of blood glucose. However, the controlled environment of the study should be considered and patient education made a high priority when recommending monitors.

Percutaneous catheter closure of the persistently patent ductus arteriosus in the adult.

The USCI patent ductus occluder has been shown to be an effective nonsurgical technique for closure of the persistently patent ductus in a primarily pediatric population. Its clinical impact in the adult has been reported only within small subgroups of larger pediatric studies or for a small population. This study was conducted to determine the feasibility, success rate, and complications of device closure for the persistently patent ductus arteriosus (PDA) in the adult. The population consisted of 55 patients (4 men and 51 women; mean age 38.8 +/- 15.0 years) with follow-up of 2.2 +/- 2.1 years. All patients underwent echocardiography obtained as part of their follow-up assessment. The device was successfully placed in 54 patients, with 75% clinical and echocardiographic closure at the first follow-up assessment 2.4 +/- 2.6 months). One patient with initial clinical and echocardiographic evidence of closure was subsequently found to have an open ductus. Spontaneous closure (2 patients) or second implant (6 patients) resulted in 86% closure at the most recent assessment. Thus, the percutaneous PDA double-umbrella occluder device is a feasible and effective technique for closing persistent PDA in the adult and will result in occlusion of the shunt in most patients without the need for thoracotomy.

Bioventing pilot test results at the low point drain area, Offutt AFB, Nebraska.

The purpose of this paper was to describe the application of bioventing technology at the LPD site at Offutt AFB, Nebraska and present the results of the 15-month pilot test. The preliminary tests indicated sufficient hydrocarbon contamination was present with the necessary soil characteristics to warrant an extended bioventing pilot test. The six month in situ respiration test indicated that progress was being made in reducing the TVH concentrations and biological activity was still occurring. Laboratory analysis of the final soil samples confirmed the reduction in TRPH and BTEX concentrations indicating that the site is close to complete remediation. However, owing to reduced air flow at greater distances from the VW, more biodegradation is still needed near MPB. The reduced biodegradation at MPB could also be due to the high water tables resulting from heavy rains during the summer and fall of 1993. The local water table was above the VW and MP screens for several months. The operation of the blower will continue until the site is completely remediated. The single VW pilot test at the LPD site at Offutt AFB has proven the effectiveness of bioventing in reducing TRPH and BTEX contamination in the subsurface. The installation, operation and maintenance costs were minimal. The effectiveness of this application has resulted in three additional bioventing applications at Offutt AFB including the first, full-scale system located in the state of Nebraska.

A training tool for visual aids. Using tracing techniques to create visual aids.

PIP: This training tool explains the use of tracing techniques to create visuals requiring few materials and no training of special skills in drawing. Magazines, books, posters, and many other materials contain photographs and drawings which can be used to create visual aids for health training and public health education. The materials required are pencils, an eraser, crayons or colored marking pens, paper clips, tracing and drawing paper, carbon paper, and sources of visual images. The procedure is described. The material was prepared by INTRAH staff members. Other materials include how to evaluate teaching, how to create a family health case study and training in group dynamics.^ieng

Response of Schwann cells to mitogens in vitro is determined by pre-exposure to serum, time in vitro, and developmental age.

We compared the mitogenic response of Schwann cells freshly isolated from adult, neonatal, and embryonic nerves, and compared these cells with cells that had been cultured in serum for 5 days. DNA synthesis in response to growth factors was measured using bromodeoxyuridine and immunocytochemistry. Freshly isolated adult Schwann cells were unresponsive to growth factors with or without forskolin to elevate intracellular cAMP levels. After 5 days of culture in serum, or alternatively in defined medium containing fibroblast growth factor 2 plus forskolin, or neu-differentiation factor beta2, adult cells were responsive to mitogens, whereas cells cultured in defined medium alone remained unresponsive. Serum also increased expression of type 1 fibroblast growth factor receptor. Freshly isolated embryonic and neonatal Schwann cells in contrast responded to growth factors even in the absence of forskolin. This responsiveness changed with time in culture. Neonatal cells cultured for 5 days in defined medium in the presence or absence of serum no longer responded to FGF alone, but required forskolin for a mitogenic response. Thus, the response of freshly isolated cells to mitogens is developmentally regulated; extrinsic signals are required to render adult cells responsive to mitogens; and with time in culture, neonatal cells develop a requirement for cAMP elevation for mitogenic response.

Presence of exon 5-deleted oestrogen receptor in human breast cancer: functional analysis and clinical significance.

A variant form of the human oestrogen receptor (ER) mRNA lacking sequences encoded within exon 5 has been described (Fuqua SAW, Fitzgerald SD, Chamness GC, Tandon AK, McDonnell DP, Nawaz Z, O'Malloy BW, McGuire WL 1991, Cancer Res 51: 105-109). We have examined the expression of the exon 5-deleted ER (HE delta5) mRNA variant in breast biopsies using reverse transcriptase polymerase chain reaction (RT - PCR). HE delta5 mRNA was present in only 13% of non-malignant breast tissues compared with 32% of carcinomas (95% CI, P=0.05). Presence of the HE delta5 mRNA was associated with the presence of immunohistochemically detected ER (P=0.015) and progesterone receptor (PR) (P=0.02). There was a positive correlation between the presence of HE delta5 and disease-free survival (P=0.05), suggesting that the presence of HE delta5 may be an indicator of better prognosis. We have raised a monoclonal antibody specific to the C-terminal amino acids of HE delta5. This antibody recognized the variant but not the wild-type ER protein. We show that HE delta5 protein is present in breast cancer using immunohistochemical techniques. We also analysed trans-activation by HE delta5 in mammalian cells and showed that, in MCF-7 cells, HE delta5 competes with wild-type ER to inhibit ERE-dependent trans-activation. Our results indicate that this variant is unlikely to be responsible for endocrine resistance of breast cancer, but its presence at both the mRNA and protein level suggest that it may, nevertheless, be involved in regulating the expression of oestrogen-responsive genes in breast cancer.