Cardiac output response to dynamic exercise after atrial switch repair for transposition of the great arteries.

Results from this study showed that patients who underwent successful operation for transposition of the great arteries had no appropriate increase in stroke volume in response to exercise of a nature similar to common recreational activities. The impairment, most likely due to disturbances in both venous return and ventricular systolic function, is compensated for by an increase in peripheral oxygen extraction; however, this increase may not be adequate with maturation or during prolonged exercise when cardiovascular constraints are more important.

Consumer products and hospitalized burn injuries among elderly Massachusetts residents.

This study is based on data for Massachusetts residents who were burned between July 1, 1978 and June 30, 1979 and who were treated as hospital inpatients in any of the 240 hospitals participating in the New England Regional Burn Program. Demographic information and information regarding the nature of the burn injury and consumer products involved were obtained by review of the medical record for each case. One hundred seven (9%) of the 1237 burn victims identified were aged 65 years or older, yielding a burn incidence rate equal to 15.5 burns per 100,000 person-years compared with a rate of 23.8 burns per 100,000 person-years for younger Massachusetts residents. The burn mortality rate for the elderly who survived long enough to be hospitalized was 2.6 deaths per 100,000 person-years compared with a rate of 0.4 deaths per 100,000 person-years for younger individuals. For survivors, the average length of hospital stay for elderly victims was 28.6 days compared with 12.0 days for younger individuals. Clothing ignition, stoves and ovens, smoking materials, and bathroom showers and tubs contributed significantly to the causes of burning among the elderly. In addition, evidence was found suggesting that elderly patients receive medical care relatively later after injury, thus considerably complicating their illness.

International environmental health: priorities from Huairou.

Between August 30 and September 8, 1995, 38,000 women and several hundred men met in Huairou, China, to discuss the global status of women and to lobby for specific wording in the Agenda for Women that was being finalized in Beijing as part of the United Nations Fourth World Conference on Women. This article has two main objectives. The first objective is to summarize the priority concerns identified in Huairou that are related to international environmental health, especially concerns related to women. The second objective is to provide the rationale and documentation that support including these topics as part of professional education and practice in environmental health in the United States. It is hoped that this discussion will aid environmental health professionals in better appreciating the connection between global environmental health problems and local problems and the applicability of gender-relevant environmental health concerns to local programming, policies, and infrastructure.

Evidence against multiple premenstrual syndromes: results of a multivariate profile analysis of premenstrual symptomatology.

The topic of a single vs multiple premenstrual syndromes has generated much discussion. In this study, multivariate profile analysis was used to determine whether or not physical and affective symptoms associated with the premenstrual syndrome (PMS) could be explained as the manifestation of one underlying pathophysiologic process. The premenstrual symptom profiles of 820 undergraduate students and 485 graduate students were evaluated. It was not possible to reject the null hypothesis of parallel profiles in most comparisons, suggesting that variability in the severity of premenstrual symptoms may be the result of individual differences in the expression of one underlying pathophysiologic process.

"Whiplash associated disorders: redefining whiplash and its management" by the Quebec Task Force. A critical evaluation.

STUDY DESIGN: The two publications of the Quebec Task Force on Whiplash-Associated Disorders were evaluated by the authors of this report for methodologic error and bias. OBJECTIVES: To determine whether the conclusions and recommendations of the Quebec Task Force on Whiplash-Associated Disorders regarding the natural history and epidemiology of whiplash injuries are valid. SUMMARY OF THE BACKGROUND DATA: In 1995, the Quebec Task Force authored a text (published by the Societe de l'Assurance Automobile du Quebec) and a pullout supplement in Spine entitled "Whiplash-Associated Disorders: Redefining Whiplash and its Management." The Quebec Task Force concluded that whiplash injuries result in "temporary discomfort," are "usually self-limited," and have a "favorable prognosis," and that the "pain [resulting from whiplash injuries] is not harmful." METHODS: The authors of the current report reviewed the text and the supplement for methodologic flaws that may have threatened the validity of the conclusions and recommendations of the Quebec Task Force. RESULTS: Five distinct and significant categories of methodologic error were found. They were: selection bias, information bias, confusing and unconventional use of terminology, unsupported conclusions and recommendations, and inappropriate generalizations from the Quebec Cohort Study. CONCLUSION: The validity of the conclusions and recommendations of the Quebec Task Force regarding the natural course and epidemiology of whiplash injuries is questionable. This lack of validity stems from the presence of bias, the use of unconventional terminology, and conclusions that are not concurrent with the literature the Task Force accepted for review. Although the Task Force set out to redefine whiplash and its management, striving for the desirable goal of clarification of the numerous contentious issues surrounding the injury, its publications instead have confused the subject further.

A review and methodologic critique of the literature refuting whiplash syndrome.

The validity of whiplash syndrome has been a source of debate in the medical literature for many years. Some authors have published articles suggesting that whiplash injuries are impossible at certain collision speeds; others have stated that the problem is psychological, or is feigned as a means to obtain secondary financial gain. These articles contradict the majority of the literature, which shows that whiplash injuries and their sequelae are a highly prevalent problem that affects a significant proportion of the population. The authors of the current literature critique reviewed the biomedical and engineering literature relating to whiplash syndrome, searching for articles that refuted the validity of whiplash injuries. Twenty articles containing nine distinct statements refuting the validity of whiplash syndrome were found that fit the inclusion criteria. The methodology described in these articles was evaluated critically to determine if the authors' observations regarding the validity of whiplash syndrome were scientifically sound. The authors of the current critique found that all of the articles contained significant methodologic flaws with regard to their respective authors' statements refuting the validity of whiplash syndrome. The most frequently found flaws were inadequate study size, nonrepresentative study sample, nonrepresentative crash conditions (for crash tests), and inappropriate study design. As a result of the current literature review, it was determined that there is no epidemiologic or scientific basis in the literature for the following statements: whiplash injuries do not lead to chronic pain, rear impact collisions that do not result in vehicle damage are unlikely to cause injury, and whiplash trauma is biomechanically comparable with common movements of daily living.

An assessment of the completeness of the Massachusetts Burn Registry.

An opportunity to assess the completeness of reporting to the Massachusetts Burn Registry arose when data on the incidence of inpatient burns in Massachusetts became available from an independent source, the New England Regional Burn Program. The assessment showed that the level of reporting to the registry was approximately 20 percent and that substantial geographic variability existed. Other areas in which the registry is experiencing difficulties that bear on its potential usefulness include confusion about the type of burns that are reportable, lack of adequate control of data quality, and insufficient funds to support the registry's activities. Continuation of the present burn reporting system does not seem defensible in the absence of changes in either the reporting requirements or the reporting methods, because the level of reporting is low, the quality of the data is unknown, and the registry is not achieving goals of substantial public health importance.

Socioeconomic factors and burn rates in persons hospitalized for burns in Massachusetts.

To assess the usefulness of routinely collected socioeconomic variables from the U.S. census in predicting burn incidence rates, burn rates and 25 socioeconomic variables were analyzed at the level of census tracts for the Boston Standard Metropolitan Statistical Area. The burn rates were based on data collected during the National Burn Demonstration Project and consisted of patients who sustained burns between July 1, 1978, and June 30, 1979, and who required inhospital care. Analysis of the data revealed strong associations between burn rates and six of the variables. The six variables were the percentage of families below the poverty level with a householder under age 65 years, the percentage of persons over 5 years of age whose residence in 1975 was a different dwelling but in the same county, the percentage of persons in the civilian labor force who were unemployed at the time of census enumeration, the average age of occupied dwelling units, the percentage of occupied housing units occupied on a rental basis, and the percentage of persons age 25 years or older who acquired some college education but did not complete college. Interpretation of the findings is not straightforward but seems to suggest that the previously observed association between poor socioeconomic status and increased burn risk for individuals can be quantified at the census tract population level.

Enhancing the quality and usefulness of epidemiological studies of burn injuries.

The objectives of this manuscript are to highlight how certain features of epidemiological studies of burn injuries affect the quality of the investigation and the usefulness of the results, and to suggest a framework, in the form of a checklist, for future submissions of epidemiological studies to Burns.

Landmarks in burn prevention.

The objective of this paper is to highlight landmarks in burn prevention. Novel strategies in the areas of law and regulation, environmental and consumer product design, and educational programs are identified and discussed. Notwithstanding marked reductions in burn morbidity and mortality, especially in economically developed countries, burn injuries remain an important public health concern throughout the world. More, and more effective, burn prevention programs coupled with renewed efforts to reduce the social and environmental correlates of burn injuries (poverty, overcrowding, family stress, and educational deficits) are needed to further reduce burn incidence and its long-term sequelae.

Paediatric burn injuries in New England, USA.

The authors analysed a subset of data from the New England Regional Burn Program (NERBP) to describe the epidemiology of burn injuries for children aged from birth to 19 years in the six-state New England area of the USA. The subset of the NERBP data analysed pertained to residents of the six New England states who were admitted to hospital for the treatment of a burn injury sustained between 1 July 1978 and 30 June 1979. Analysis of the data revealed that 1128 (41 per cent) of the 2742 hospitalized burns identified occurred to persons between the ages of birth and 19 years, yielding an overall burn incidence rate of 30.7 burns per 100,000 person-years. Children aged from birth to 2 years sustained a higher burn rate, 96.7 burns per 100,000 child-years, than did children in any other age category. The burn rate for males was higher than the rate for females in each age category, as were the rates for black children compared to white children. Children in Massachusetts experienced the highest overall burn rate among the six New England states; the lowest rate occurred in New Hampshire. Overall, 63 per cent of the burns occurred in a residential setting. The most common activities related to burn injury were food preparation and food consumption, which accounted for 471 (42 per cent) of the burn injuries.

Socioeconomic factors and the incidence of hospitalized burn injuries in New England counties, USA.

This study demonstrates that readily available socioeconomic data routinely collected by the US Census can be used to estimate the incidence of burn injuries within the 66 counties of the populous six-state New England region of the USA. The burn data were collected during the National Burn Demonstration Project and included New England residents admitted for hospital care of burns sustained between 1 July 1978 and 30 June 1979. Linear regression analysis revealed strong associations between calculated burn rates and a number of socioeconomic variables. Associations with five such variables are described, including per capita income, percentage of persons below poverty level, percentage of residences built prior to 1940, percentage of adults with 16 years or more of education, and percentage of persons moving since 1975 with previous residence in the same county. Estimates of burn incidence for counties, together with a previously reported study at the level of census tracts for a major Standard Metropolitan Statistical Area, can be used to reduce the time and cost of burn injury case reporting by health care providers or case-finding efforts for large population groups, and can be used to predict the effectiveness of social and economic programmes and policies that improve the overall well-being of county populations.

Prevalence and severity of the premenstrual syndrome. Effects of foods and beverages that are sweet or high in sugar content.

The objective of this study was to evaluate whether certain foods and beverages that are high in sugar content or taste sweet are related to the prevalence and severity of the premenstrual syndrome. Specifically, we sought to evaluate whether consumption of "junk foods", chocolate, caffeine-free cola, fruit juices or alcoholic beverages might exert an effect on the premenstrual syndrome apart from any effects of daily consumption of beverages that are high in caffeine (caffeine-containing coffee, tea and colas). The study was based on 853 responses to a questionnaire probing menstrual and premenstrual health and certain daily dietary practices; it was mailed to female university students in Oregon. An analysis of the data revealed that the consumption of chocolate, but not of other junk foods, was related to the prevalence of the premenstrual syndrome among women with more severe premenstrual symptoms. Likewise, the consumption of alcoholic beverages (all alcoholic beverages and beer only) was related to the prevalence of the premenstrual syndrome among women with more severe symptoms, as were both fruit juice and caffeine-free soda. None of the associations was substantially altered when the daily consumption of beverages high in caffeine content was controlled for. Taken together, these data suggest that the consumption of foods and beverages that are high in sugar content or taste sweet is associated with prevalence of the premenstrual syndrome.

[120 cases of the Williams and Beuren syndrome]. / Etude de 120 observations de syndrome de Williams et Beuren.

120 cases of the Williams-Beuren syndrome were collected by 11 cardiological centres in France, to determine the incidence of the various clinical signs and to obtain information on its aetiology, outcome and treatment. The selection criteria for inclusion in the series was typical facies. No particular complications were reported during pregnancy. Boys were a little more affected than girls. The birth weight was low and problems, especially digestive, often occurred in the first months. Cardiac signs were usually detected from the first year, although the exact diagnosis was usually made later on. 3/4 patients had subaortic stenosis, which was severe in 1/3 cases. Involvement of the branches of the aorta was not looked for systematically: the incidence (1/5 cases) found was lower than the true figure. Half the patients also had stenoses on branches of the pulmonary artery, but only rarely were they severe. These vascular malformations often seem to be progressive and, over a 10 year period, half the patients deteriorated. Many extracardiac abnormalities were reported. The most frequently encountered were inguinal and/or umbilical hernia. Surgery on the subvalvular stenosis gave good results in over 80 p. 100 cases; operative mortality was about 10 p. 100. Surgery should be performed before irreversible coronary or myocardial lesions develop. The study of the previous history did not give any new information on the cause of the syndrome, whose association with idiopathic hypercalcaemia of infancy is emphasised once again.

[Restrictive ostium secundum: a new fetal malformation syndrome]. / L'ostium secundum restrictif: un nouveau syndrome malformatif foetal.

Echocardiographic examination of a 23 weeks' hydropic fetus disclosed abnormal kinetics of the valve of the foramen ovale. This valve was constantly bulging out, dome-like, into the left atrium, and on TM-mode tracings in transatrial projection the alpha and beta peaks which occur respectively during the opening and closure of the atrioventricular valves throughout fetal life were missing. This anomaly suggested that the ostium secundum was restrictive; the foramen ovale itself was not restrictive. Such abnormal kinetics have not been encountered among 16 other cases of hydrops fetalis of cardiac or other origin, or in a control series of 81 normal fetuses, which clearly shows that the restriction was primitive. At birth, the child presented with aneurysm of the foramen ovale, probably due to the restrictive ostium secundum.

[Transient myocardial ischemia and isolated congenital mitral valve prolapse in an infant]. / Ischémie myocardique transitoire et prolapsus valvulaire mitral congénital isolé chez un nourrisson.

The investigation of a cardiac murmur in a 9 month old infant led to the clinical, echo and angiographic diagnosis of congenital mitral regurgitation due to isolated mitral valve prolapse, whereas the electrocardiogram showed signs of inferior myocardial ischaemia which regressed in a week. The valvular dysfunction of mitral valve prolapse has been held responsible for coronary spasm ischaemia and infarction in adults. This complication has not been previously reported to our knowledge in infancy.

[Angelman syndrome and severe vagal hypertonia. Three pediatric case reports]. / Syndrome d'Angelman et hypertonie vagale sévère. A propos de trois observations pédiatriques.

Angelman's syndrome is an association of severe mental retardation with absence of language, ataxia, convulsions and hyperactive, joyful behaviour with frequent bouts of laughing. Genetic diagnosis is possible in about 80% of cases. No cardiovascular abnormalities have been described in this syndrome to date. The authors report the cases of three children with Angelman's syndrome who presented with severe malaise due to increased vagal tone. The age of onset of symptoms was between 20 months and 8 years. One of the children had malaises triggered by bouts of laughing. The diagnosis was confirmed in all three cases by the results of Holter 24 hour ECG recording and oculo-cardiac reflex. The treatment chosen was Diphemanil (Prantal) in the two patients under 2 years of age (after failure of a trial of betablockers in one case) and Disopyramide for the oldest child with excellent results in all cases. However, one child died suddenly at the age of 6, two years after stopping diphemanil. Based on these observations, the authors suggest that all malaises in patients with Angelman's syndrome should be investigated by Holter ECG and oculo-cardiac reflex (or tilt test). In view of the potential gravity of the syncopal attacks, long-term medical treatment seems to be justified.

[Heart malformations and vascular complications associated with Turner's syndrome. Prospective study of 26 patients]. / Malformations cardiaques et complications vasculaires associées au syndrome de Turner. Etude prospective chez 26 patientes.

Turner's syndrome is associated with congenital heart disease in a third of cases. Several reports of aortic dilatation and of death by dissection or rupture of the aorta have been published. The authors undertook a prospective study to assess the incidence of cardiac malformations and aortic dilatation in genetically confirmed Turner's syndrome. Twenty-six out of 34 patients recalled (76%), aged 7 to 30 years (average 17 +/- 6 years) accepted their inclusion in this study and underwent clinical examination, ECG, chest X-ray and echocardiography. Thirteen patients had a monosomy 45X and 13 a mosaic or structural abnormality. Six had a history of cardiovascular disease (operated coarctation: 2 cases, kinking: 2 cases, Hypertension: 2 cases). Eight patients (30%) had one or several anatomical cardiovascular abnormalities: bicuspid aortic valve (19.2%), abnormalities of the aortic isthmus (kinking or coarctation) (15.4%), aortic regurgitation (7.7%), mitral stenosis (3.8%), partial anomalous venous drainage (3.8%), patent ductus arteriosus (3.8%) and left superior vena cava (11.5%). Systematic evaluation of the aorta resulted in the diagnosis of dilatation of the ascending aorta in 1 case and dilatation of the sinus of Valsalva in 2 other cases. The authors conclude that echocardiographic evaluation is essential after the diagnosis of Turner's syndrome. It should be repeated regularly to detect dilatation of the aorta which carries the risk of serious complications, such as rupture or dissection of the aorta.

[Cardiac output evaluation during exercise in children treated with atrial surgery for transposition of great vessels]. / Evaluation du débit cardiaque à l'exercice chez des enfants traités par chirurgie atriale d'une transposition des gros vaisseaux.

The long-term physiopathological consequences of atrial surgery (Senning or Mustard procedures) for transposition of the great vessels with respect to exercise capacity are not well known. We measured the cardiac index by the technique of CO2 rebreathing at two submaximal levels of exercise corresponding to a stable oxygen consumption of 20 (E20) and 30 (E30) ml/min/kg in 7 patients successfully operated for transposition of the great vessels and in 7 control children paired for age, gender and body surface area. Despite an identical chronotropic response to exercise in the two groups, the increase in cardiac index was not as great in the children operated for transposition (from 6.86 +/- 0.51 to 7.71 +/- 0.78 l/min/m2) as in the control population (from 7.71 +/- 0.78 to 10.2 +/- 0.51 l/min/m2; p < 0.02). The stroke volume index was therefore significantly lower in the transposition group at both levels of exercise (52 +/- 3.2 vs 63 +/- 4.1 ml/m2; p < 0.04 at E20; and 46.4 +/- 4.3 vs 66 +/- 5.1 ml/m2 at E30). The main cause of this reduction of the stroke volume index is probably a lack of adaptation of right ventricular systolic function on exercise but it is not possible to exclude diastolic dysfunction due to reduce compliance secondary to the intraatrial patch. The conditions of preload are in fact instrumental in increasing stroke volume index at submaximal exercise levels.

[Atheromatous lesions of the proximal aorta. Severe complications of homozygous type IIa hypercholesterolemia in children]. / Les lésions athéromateuses de l'aorte proximale. Complications graves de l'hypercholestérolémie type IIa homozygote chez l'enfant.

Coronary lesions with atheromatous deposits occurring in later childhood characterize homozygous type IIa hypercholesterolaemia and condition the somber prognosis of a disease which affects one subject in a million. However, aortic lesions are constantly found, as shown by routine ultrasonographic and angiographic studies in these children. The walls of the proximal aorta are cardboard-like and thick, the origin of the aorta is narrow and the semilunar aortic valves are thickened. The valvular or supravalvular aortic gradient may be considerable; it is often progressive, but is sometimes stabilized or made regressive by medical treatments combined with plasmapheresis or porto-caval shunt. Aortoplasty or aortic valve replacement being difficult to perform in these patients, more aggressive therapeutic procedures, such as liver or heart transplantation, have been suggested. The last generation cholesterol-lowering drugs seem to offer some hope of success.