Biomedical subjects
Publications and source records attributed to O Reich.
Right-sided BSCA provides for satisfactory pulmonary arterial growth in infants and children with complex congenital heart defects, and it could enhance the growth of a small right pulmonary artery. The growth of the left pulmonary artery, particularly in younger patients, needs close attention to confirm the safe role of BSCA in long-term palliation.
BACKGROUND: It is common practice to interrupt all alternative sources of pulmonary blood flow ("competitive flow") at the time of a bidirectional superior cavopulmonary anastomosis (BCPA), although the merits of this have not been systematically studied. METHODS AND RESULTS: We reviewed the early and medium-term clinical and hemodynamic findings in 108 consecutive patients 3 weeks to 25 years old (median, 1.9 years) undergoing BCPA at one of three institutions. Preoperatively, pulmonary blood flow was dependent on antegrade ventricular flow (n = 50), systemic-to-pulmonary shunts (n = 33), or mixed sources (n = 25). Postoperatively, competitive sources of pulmonary blood flow were left patent in 43 of 108 patients (40%). There were four early (3.7%) and four late deaths, none related to persistence of competitive flow. After BCPA, patients with competitive flow had significantly higher systemic oxygen saturations at 1 hour (85% versus 79%), 24 hours (84% versus 78%), and at hospital discharge (84% versus 78%) and required a shorter period of artificial ventilation (median, 9 versus 24 hours) and intensive care (median, 2 versus 4 days). Oxygen saturations at late follow-up (median, 2.8 years; range, 1 to 7) did not differ (83% versus 82%). No patient developed pulmonary arteriovenous malformations. CONCLUSIONS: Competitive flow is well tolerated in the short and medium term after BCPA, and early postoperative systemic oxygen saturations are improved. The long-term influence of competitive flow on pulmonary arterial growth, arteriovenous malformation development, and ventricular function warrants investigation.
The purpose of this study was to extend previous observations of a greater decrease in tidal volume in infants than in children during halothane anaesthesia. We analyzed the inspiratory flow waveform recorded during spontaneous ventilation in: infants, two to six months of age, and children, one to five years of age. In addition we analyzed the CO2 signal and the pressure waveform during an occluded inspiration. The pressure generated during the initial 100 msec of inspiratory occlusion, an index of respiratory drive, was analyzed to give some insight into the aetiology of the age-related differences. In 15 infants and 15 children, Flow (V), pressure (Pao) and PCO2 were recorded at three concentrations of inspired halothane (FIH): 0%, 1% and 2% which correspond to an endtidal halothane concentration of about 0.3%, 0.9% and 1.3% respectively. Data were analyzed for minute ventilation (Vi) and parameters of timing (Total time (Ttot), Inspiratory time (Ti)), the amplitude of the neural output (mean inspiratory flow (VT/Ti), tidal volume (VT)) and the shape of the inspiratory breath profile (the inspiratory centroid flow (Ci/Ti), the inspiratory duty cycle (Ti/Ttot)). In some, the airway was occluded at end expiration and the slope of the initial 100 msec of occlusion (dP/dt) together with the maximal negative pressure (PMAX) were measured. Estimates of respiratory mechanics E'rs (PMAX/VT) and (VT/Ti)/(dP/dt) were obtained. The VT and Ttot decreased with increasing FIH in both infants and children (P < 0.05). The PETCO2 increased in both groups and the % increase was greater in infants.(ABSTRACT TRUNCATED AT 250 WORDS)
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The spectrum of patients operated on without preoperative catheterization and angiography, the accuracy of echocardiographic diagnosis and its impact on the results of surgical treatment were prospectively assessed in 2,788 children consecutively operated for congenital heart defects (CHD) between 1986 and 1992. The overall percentage of surgery based solely on noninvasive preoperative examination increased from 63% in 1986 to 81% in 1990 and decreased to 72% in 1992. There were no differences in the preoperative diagnostic approach between groups of newborn, infants and children. A high percentage of patients with patent ductus arteriosus (96.5%), atrial septal defect (94%), incomplete atrioventricular septal defect (88.6%), ventricular septal defect (86.3%), coarctation of the aorta (80.2%) and total anomalous pulmonary venous connection (79.3%) was referred for surgery without prior invasive examination, while a lower percentage was found in univentricular heart (48.4%), pulmonary atresia (34.6%) and double outlet right ventricle (27.7%). More patients with pulmonary and tricuspid atresia were catheterized before complete repair compared to those who underwent palliative surgery (p < 0.01 and p < 0.0001, respectively). The echocardiographic diagnosis was correct in 96% of patients. Two patients of those with incomplete preoperative diagnosis died early postoperatively, both with missed apical ventricular septal defect. One with tetralogy of Fallot died after reoperation, the other with persistent truncus arteriosus due to sepsis. When the echocardiographic findings are in full agreement with the clinical status, physical examination, ECG and chest X-ray, we recommend cardiac surgery without prior catheterization in many patients with CHD.
We studied the amplitude, timing, and shape of the airflow waveform at the mouth of spontaneously breathing children under two sets of conditions: 1) in 30 children aged 9 wk-4.5 yr at 2, 1, and 0% inspired halothane concentration and 2) in 22 children aged 5 mo-7 yr during hyperoxic CO2 rebreathing while recovering from anesthesia. Compared with control values, the relative changes in breath parameters at 1 and 2% halothane were, respectively, as follows: total cycle time -19 and -31%, tidal volume (VT) -30 and -44%, minute ventilation -11 and -17%, and VT/inspiratory time (TI) -16 and -20%. Parameters of timing and breath shape did not change except for the significant but small increase in TI/total cycle time (by 6 and 8%, respectively). With CO2 rebreathing, parameters reflecting inspiratory drive increased significantly in all patients as shown by the slopes of the regressions of these parameters against end-tidal PCO2. Mean slopes expressed in %control value per millimeter of mercury CO2 were 12.1 for minute ventilation, 8.3 for VT, and 10.67 for VT/TI. Parameters reflecting the timing and breath shape remained essentially unchanged. Our results suggest that, in children under halothane anesthesia, the amplitude, timing, and shape of the breathing pattern are controlled independently. In particular, the amplitude and timing of the breath may vary widely without any significant change in the shape.
The histological grading of 29 ductal pancreatic carcinomas was compared with that of silver stained NOR-associated proteins and with p53 immunoreactivity. The AgNOR number (NZ) and AgNOR areas (NF) of 10 grade I carcinomas, 13 grade II carcinomas and 6 grade III carcinomas were investigated by image analysis. Furthermore, the protein expression of the p53 gene was examined by immunohistochemistry. A significant difference was found in both AgNOR parameters between grade I, grade II and grade III carcinomas (NZ: p < 0.01; NF: p < 0.05; grade I carcinomas: NZ 5.1/NF 8.2 microns 2; grade II carcinomas: NZ 6.0/NF 11.3 microns 2 grade III carcinomas: NZ 8.4/NF 15.2 microns 2). By contrast no relation was found between histological grading and p53 immunoreactivity. In 56% of all carcinomas positive evidence was found of the p53 gene product. (6 grade I carcinomas, 7 grade II carcinomas, 3 grade III carcinomas). 44% of the cases were p53-negative (4 grade I carcinomas, 6 grade II carcinomas, 3 grade III carcinomas). This study demonstrates that the AgNOR technique is useful in the grading of ductal pancreatic carcinomas, whereas the expression of the p53 gene product is not.
Eight case reports of the so-called stromatosis uteri (SU) are presented, followed by explanations on pathological anatomy, immunohistochemistry, biological behaviour and histogenesis of this rare sarcoma entity. Finally, therapy is discussed.
Total cavopulmonary connection (TCPC) allows surgical treatment of patients with complex univentricular heart disease. Between 1991 and 1993 this operation was performed in 15 cyanotic children with complex heart defects. Age range was 3.5-14 (median 8.3) years. In 5 children with increased operative risk a calibrated interatrial fenestration was created intraoperatively to allow systemic venous decompression. Three patients (20%) died. In remaining 12 patients a significant increase in arterial oxygen saturation and decrease of polycythemia was encountered. All patients remain in a good clinical condition 1-25 months after operation. Noninvasive investigation including echocardiography confirmed good function of the heart.
In the child cardiocentre in Prague 5-Motol in 1977-1993 a total of 420 neonates with critical inborn heart disease were operated. Obstructive defects of the left heart were found in 178 children, obstructive defects of the right heart in 87, defects with a left-right shunt with pulmonary hypertension in 75, conotruncal malformations in 73 and various operations were made in 7 children. Complete repair of the defect was achieved in 281 neonates, incl. 104 where extracorporeal circulation was used. Palliative operations were made in 139 children. Early mortality during the entire period was 26%, whereby a decrease from 40% to 16% was recorded during the last three years. At present it is possible to repair permanently critical inborn heart disease in the majority of neonates. This is made possible in particular by early non-invasive diagnosis, treatment with prostaglandins E in duct-dependent critical heart disease, optimal time for and selection of most suitable surgery, microsurgical technique, miniaturization of extracorporeal circulation and the method of deep hypothermia.
Bidirectional cavopulmonary anastomosis was used during the past six years for palliative treatment of 34 children with complex cardiac disease with a low pulmonary blood flow and a functional common ventricle. The age at the time of operation was 5 months to 16 years (median 55 months). Two children (5.9%) died soon after operation and one patient died in conjunction with reoperation seven months later. After operation a significant increase of saturation and decrease of the haematocrit occurred in all patients. The condition of 31 patients during an out-patient check-up 2-64 months after operation was satisfactory and postoperative examinations revealed a satisfactory function of the anastomosis.
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The general biologic behaviour of exocrine pancreatic cancer was examined retrospectively in a total of 840 autopsies (382 males, aged 31-86 [average 66.5] and 458 females, aged 2-90 [average 72]). 95 % of autopsies showed definable tumours (caput 64%, corpus 17%, cauda 14%), in 5% the gland was diffusely permeated by cancer tissue. 19.5% had no metastases, whereas in 80.5% carcinomatosis was diagnosed. In 7% only locoregional metastases of the lymph nodes could be found. Tumour sizes were observed in the range of 0.3 to 14 cm. All carcinomas below the size of 1 cm were free of metastases. In tumours larger than 2 cm, the formation of metastases increased sharply. In sizes more than 3 cm complications were important for the prognosis. Carcinomatosis proceeds cascade-fashion with high first rate metastatic spread into the liver. 6% of liver metastases were solitary ones, 94% were multiple. In 171 cases malignancy grading was performed. Free of metastases were 50% of the decreased with grade-I-carcinomas, 21% with grade-II-carcinomas and 7% with grade-III-carcinomas. These data comment on the possibilities and limitations of curative cancer resection from a morphological view.
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The diagnostic reliability of echocardiography (ECHO) was analyzed in a group of 179 children operated on account of an atrial septal defect (ASD) and partial anomalous pulmonary venous drainage (PAPVD). A total of 223 individual types of ASD and PAPVD and their mutual combinations were proved on operation. In all patients indirect signs of a left-to-right shunt at the atrial level was proved. The sensitivity and specificity of ECHO examinations in the ASD type fossa ovalis was 0.97 and 0.80 resp., in ASD type sinus venosus it was 0.47 and 0.98, in PAPVD 0.38 and 0.99. In both types of ASD type sinus coronarius assessed on operation the ECHO diagnosis was correct. The application of colour Doppler technique increased the reliability of the ECHO examination. The accuracy of ECHO in ASD and PAPVD depends indirectly on age, body weight and body surface. No relationship was proved between reliability of ECHO diagnosis of the defect and the magnitude of the left-to-right shunt assessed by radiocirculography and the size of the defect assessed during operation. In no instance the diagnostic inaccuracy affected the surgical approach and the result of the operation. Despite certain diagnostic pitfalls, it is therefore possible to operate, using the comprehensive non-invasive examination procedure, children with these anomalies in our department without previous cardiac catheterization and angiography.
A rare case of the abnormal origin of the right coronary artery is demonstrated in a two-year-old boy with an aortopulmonary window and subvalvular membranous aortal stenosis. The diagnosis was established by angiography before operation by injection of contrast substance into both great arteries. Surgical repair of the complicated defect comprised also derivation of the orifice of the right coronary artery into the aorta. The long-term postoperative follow-up indicates relatively favourable results with signs of impaired myocardial perfusion in the area supplied by the right coronary artery.
In the catchment area of two Pathological Institutes in Saxony with a population of approximately 1.3 million people all autopsies with the diagnosis of exocrine pancreatic cancer were evaluated with respect to age and the number of autopsies carried out in the period of the past ten years (1979-1988). The trend of this type of cancer within this group of all dissected cancer patients was followed. Absolute increase rates of 48% for males and 32% females could be calculated. An increasing incidence of pancreatic cancer was observed not only in the 7th and 8th decade of live--as was typical so far--but also from the age of 50 years onwards. Rates of increase were also found with regard to all cancer autopsies: 6% for males and 34% for females. The data agree with other observations of an increased pancreatic cancer incidence in all industrialized countries.
In order to assess the range of normal values of radionuclide ventriculography the authors selected retrospectively 53 normal children and adolescents. All were examined by radionuclide angiocardiography on account of clinical and echocardiographical suspicion of congenital heart disease with a left-to-right shunt; a significant shunt was, however, excluded. In all patients after equilibration of the radiotracer ventricular function was examined by radionuclide ventriculography. The authors evaluated the usual volume, time and rate characteristics. The normal range was defined as the mean +/- 2 standard deviations which is for the ejection fraction of the left ventricle 47 to 72% and for the ejection fraction of the right ventricle 31 to 56%. The other results are discussed in detail in the text.