Biomedical subjects
Publications and source records attributed to A Garson.
A child was treated for thoracoabdominal ectopia cordis and an associated chromosomal defect. Contrary to most cases in which death is due to the externally situated heart and abdominal viscera, this patient died from congenital heart disease.
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Varicella is usually a well-tolerated disease in normal children. Pyogenic infections involving the skin are the commonest complications and their potential severity is emphasized by our recent experience with two children who suffered from gangrene as a result of cutaneous superinfection with group A beta-hemolytic streptococci. We present the recognition and management of these patients in an effort to reacquaint physicians with this potentially fatal infection.
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Limited data are available on the electrocardiogram and ambulatory electrocardiogram recording (Holter) in children infected with the human immunodeficiency virus type 1 (HIV-1). The purpose of this study was to estimate the prevalence and cumulative incidence of rhythm and conduction abnormalities in HIV-1-infected children. Electrocardiograms and Holter monitoring studies were performed annually on 205 HIV-1-infected children enrolled after 28 days of life (group I), 93 HIV-1-infected infants enrolled during pregnancy or during the first 28 days of life (group IIa), and 463 HIV-1-uninfected infants enrolled during pregnancy or during the first 28 days of life (group IIb). The 5-year cumulative incidence in the group I children of second-degree atrioventricular block or supraventricular or ventricular tachycardia was 13.4%, and the 5-year incidence was higher for the older infected group I children (16.8% for children > or =4 years old at first study and 11.4% for children <4 years, p = 0.04). The mean corrected QT interval was also longer for the older infected group I children (p = 0.002) and prolonged in the HIV-1-infected compared to the HIV-1-uninfected group II children (p = 0.02). None of the children had atrial fibrillation or flutter. Arrhythmias are uncommon in children infected with HIV-1 and in children of HIV-1-infected mothers and the arrhythmias identified tend to be benign. Therefore, routine Holter monitoring does not appear to be indicated in asymptomatic children.
Branch pulmonary artery stenosis is a common problem in pediatric cardiology. Treatment has included surgery, balloon angioplasty, and balloon expandable stent placement. It was the purpose of this investigation to demonstrate the cost-effectiveness of each of these modes of treatment. From 1983 to 1994 there were 30 patients admitted for treatment of branch pulmonary artery stenosis only. Data included age at procedure, sex, primary diagnosis, acute and intermediate term success, and complications. Acute success was defined by results at the end of the procedure where intermediate term (IT) success was defined by results at follow-up. Success of a procedure was defined by at least one of the following: an increase in vessel diameter by >/=50% of predilation diameter, a decrease in right ventricular to left ventricular or aortic systolic pressure ratio by >/=20%, or a decrease in peak to peak pressure gradient by >/=50%. The procedure was considered a failure if the previously mentioned criteria were not met or if the patient required a second procedure for the same stenosis. The expense of the procedure (estimated by using the patient charges) were collected from the time of the procedure until December 1994. Because of differing lengths of follow-up, the patients were analyzed separately for procedures and outpatient charges. The total charges were corrected to 1994 dollars using the Medical Consumer Price Index. Thirty patients had 46 separate procedures (12 patients had >1 procedure and 3 had >2 procedures). There were 13 surgeries, 13 balloon angioplasties, and 20 stents. Stents were the most successful (90% acute and 85% IT), but were not statistically superior to surgery (62% acute and IT). Balloon angioplasty was significantly less successful as compared with stents (31% acute and 23% IT), and was not statistically different from surgery over the acute and intermediate term. The charge data showed balloon angioplasty was the least expensive followed by stents and then by surgery. The average total charges per procedure, including outpatient charges, were: surgery $58,068 +/- $4372 (standard error), balloon $21,893 +/- $5019, stents $33,809 +/- $3533 (p < 0.001); excluding outpatient charges: surgery $52,989 +/- $3649, balloon $15,653 +/- $1691, and stents $29,531 +/- $2241 (p < 0.001). Average total charges per patient, including all procedure types and grouped by initial procedure, were: surgery $53,707 +/- $6388, balloon $50,040 +/- $8412, and stent $34,346 +/- $3488 (p = 0.047). Stents were at least as effective as surgery and were more effective than balloon angioplasty in both acute and intermediate term follow-up. Balloon angioplasty was least expensive per procedure but was also least effective. Therefore, intravascular balloon expandable stents are the most cost-effective means available in the treatment of branch pulmonary artery stenosis.
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With the recent high visibility deaths of Hank Gathers and Reggie Lewis, two nationally recognized elite basketball players due to cardiovascular disease and arrhythmias, our awareness of the most optimal ways to manage athletes with known arrhythmias has become heightened. In making medical decisions we physicians come to rely in large measure on data, in addition to clinical acumen and experience. Unfortunately, we are at a disadvantage with respect to athletes since previously published data on the natural history and outcome of such individuals with known arrhythmias are sparse. Furthermore, the tragedies of Lewis, Gathers, Pete Maravich and others are also poignant reminders that the denominator of this equation is not defined and that we do not really know precisely how many athletes experience important arrhythmias, nor their relation to sports activity. In the decade since the 16th Bethesda Conference, an American College of Cardiology sponsored consensus panel that developed standards and recommendations for the disqualification from competition of athletes with known cardiovascular disease, little new data have been developed to make objective decisions in these areas (including arrhythmias) much easier. Nevertheless, while such decision-making in athletes involves situations that are relatively rare, the consequences of misjudgement are substantial. Unfortunately, to complicate matters, even if the precise likelihood of sudden death for a given athlete with arrhythmias were known, many (if not most) professional and elite college athletes might still regard any risk as acceptable and withdrawal from formal competition as highly unacceptable from a financial and psychological standpoint. In this review, consideration will be given to the state of our medical knowledge in these areas. Many controversies persist with regard to arrhythmias, most notably for the athlete who has Wolff-Parkinson-White, mitral valve prolapse, myocarditis, or complex ventricular arrhythmias. Finally, consideration will be given to the broader issues of how, ad physicians and members of society, we may deal with these complex issues.