[Small risk of developing Lyme borreliosis following a tick bite on Ameland: research in a general practice]. / Kleine kans op lymeborreliose na een tekenbeet op Ameland: onderzoek in een huisartsenpraktijk.

OBJECTIVE: To investigate the percentage of ticks infected with Borrelia burgdorferi on the Dutch North Sea island of Ameland, and the risk of developing Lyme disease following tick bite on the island. DESIGN: Prospective, observational. METHOD: Ticks were collected from patients who visited a general practitioner and were tested for the DNA of B. burgdorferi. After 6 months the patients were interviewed by phone using a standardised questionnaire. RESULTS: From 2004-2006, 216 ticks were collected from 167 persons. Most ticks were removed within 24 hours. In 44 ticks (20.4%) B. burgdorferi DNA was detected. Follow up information was available on 146 persons, 41 (28.1%) of whom had been bitten by a Borrelia-positive tick. None of the persons developed a typical erythema migrans. From the 13 persons (9%) reporting a non-specific redness of the skin (diameter less than 5 cm) at the site of the tick bite, 5 had been bitten by a positive tick and 8 by a negative tick. One patient bitten by a positive tick reported systemic symptoms related to Lyme borreliosis, namely fatigue, perspiration and joint ache, without local redness. CONCLUSION: The probability of developing Lyme borreliosis was low even though a relatively large percentage of the ticks collected were positive for B. burgdorferi. This is probably connected to the fact that in the majority of cases the tick had been removed within 24 hours.

Association of segmentation of the epididymal interstitium with segmented tubule function in rats and mice.

The epithelium of the epididymal tubule has different biological functions in different regions of the tubule. Each region is further organized into lobules or intra-regional segments surrounded by connective tissue septa (CTS). Epididymal segmentation has received little direct attention, yet there is considerable evidence that expression of mRNA and protein often begins or ends precisely at the CTS border of a segment. How such 'on-off' regulation occurs coincident with the passing of the tubule from one segment to the next is unknown. This study examined the segmentation of epididymides in rats and mice. The average adult Sprague-Dawley rat and C57BL/6 mouse caput, corpus and cauda epididymides has seven, two and four, and three, one and two segments, respectively. The apoptosis response of the caput epididymal epithelium to deprivation of lumicrine factors 24 h after efferent duct ligation in rats and the epididymal expression of a marker protein, beta-galactosidase, in mice were segmented precisely. This validated both at a general response and at a specific protein level that many epididymal functions are regulated within segments. Blue dextran (molecular weight 20000) and erythrocine red (molecular weight 880) dyes infused into the interstitial space of specific segments by micropuncture were retained by the CTS of the segments. In similar micropuncture experiments, [(3)H]H(2)O (molecular weight 18) was able to diffuse into an adjacent segment relatively freely whereas [(14)C]polyethylene glycol (molecular weight 4000) could not. These studies indicate that the interstitium of intra-regional segments is organized into different physiological compartments and that these compartments play a role in regulating the epididymal epithelium.

Assisted venous drainage cardiopulmonary bypass in congenital heart surgery.

BACKGROUND: A novel active venous drainage perfusion circuit was designed to achieve effective venous return through small venous cannulas. The efficacy and safety of this new system was investigated and compared with a conventional gravity drainage system. METHODS: Four hundred consecutive patients undergoing open heart repair of congenital heart lesions by one surgeon were studied. The first 200 patients were supported by gravity drainage and the next 200 patients were supported by assisted venous drainage. No patient in the time period was excluded from the study. RESULTS: The two groups did not differ significantly in weight, bypass time, or cross-clamp time. Priming volumes were less in the assisted group than in the gravity group (576+/-232 mL versus 693+/-221 mL, p < 0.001). Venous cannula size was smaller in the assisted group when compared with the gravity group (33.2F+/-7.4F versus 38.5F+/-7.1F, p < 0.001). There was a trend to lower operative mortality in the assisted drainage group (5 of 200, 2.5% versus 11 of 200, 5.5%; p = 0.10). Hospital stay and pulmonary, infectious, and neurologic complications were comparable in both groups. Cardiac complications were less common in the assisted group than in gravity group (22 of 200, 11% versus 38 of 200, 19%; p = 0.017). Hematologic complications were less common in the assisted group than the gravity group (6 of 200, 3% versus 19 of 200, 9.5%; p < 0.01). CONCLUSIONS: These findings suggest that assisted venous drainage is safe in congenital heart operations and facilitates the use of smaller venous cannulas.

New limit on the permanent electric dipole moment of 199Hg.

We present the first results of a new search for a permanent electric dipole moment of the 199Hg atom using a UV laser. Our measurements give d(199Hg) = -(1.06+/-0.49+/-0.40)x10(-28)e cm. We interpret the result as an upper limit absolute value [d(199Hg)]<2.1x10(-28)e cm (95% C.L.), which sets new constraints on theta bar;(QCD), chromo-EDMs of the quarks, and CP violation in supersymmetric models.

Rapid cardiopulmonary support for children with complex congenital heart disease.

BACKGROUND: Extracorporeal membrane oxygenation has limitations in children with congenital heart disease (prolonged setup times, increased postoperative blood loss, and difficulty during transport). We developed a miniaturized cardiopulmonary support circuit to address these limitations. PATIENTS AND METHODS: The cardiopulmonary support system includes a preassembled, completely heparin-coated circuit, a BP-50 Bio-Medicus centrifugal pump, a Minimax plus membrane oxygenator, a Bio-Medicus flow probe, and a Bio-trend hematocrit/oxygen saturation monitor. Short tubing length permits a 250-mL bloodless prime in less than 5 minutes. From 1995 to 1997, 23 children with congenital heart disease were supported with this technique. RESULTS: Overall survival to discharge was 48% (11 of 23 patients). Survival to discharge was 80% (4 of 5) in the preoperative support group, 20% (1 of 5) in the postoperative failure to wean from cardiopulmonary bypass group, 44% (4 of 9) in the group placed on support postoperatively after transfer to the intensive care unit, and 50% (2 of 4 patients) in the nonoperative group. Neonatal cardiopulmonary support survival to discharge was 46% (6 of 13 patients). CONCLUSIONS: This pediatric cardiopulmonary support system is safe and effective. Advantages over conventional extracorporeal membrane oxygenation include rapid setup time, decreased postoperative blood loss, and simplified transport.

The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease.

OBJECTIVE: A variety of stents are available to aid in the management of complex tracheal, carinal and bronchial stenoses. We reviewed our multi-institutional experience with airway stents in children. METHODS: Thirty-three children (age, 13 days-18 years) from four institutions have had a total of 40 stents placed to aid in the management of complex airway stenoses. Three stent types were utilized: 29 silastic stents, five expandable metal stents and six customized carinal stents (four patients had two stents and one patient had four stents). Thirty children had tracheal stents, six children had bronchial stents, and two infants had carinal stents (three children had stenting of more than one area and two had stenting of all three locations). Twenty-eight patients (age, 5 months-18 years; mean, 8.06 years; SEM, 1.13 years) had stents placed after a variety of airway reconstructive procedures. Four underwent stenting in a non-operative setting and one as preoperative stabilization. RESULTS: Twenty-seven patients survived. One patient died early due to bleeding. Five patients died late: two due to bleeding, one from mediastinitis, and two patients with functional airways died late from unrelated problems. Complications are related to stent type and location. Carinal stents can migrate; several techniques are available to help manage this problem. Wire stents are essentially non-removable requiring periodic dilation. Silastic stents stimulate granulation tissue formation requiring periodic bronchoscopic removal. CONCLUSION: Tracheal stenting can aid in the management of pediatric airway problems. Complications are common, but can be managed with appropriate intervention.

Presentation of the International Nomenclature for Congenital Heart Surgery. The long way from nomenclature to collection of validated data at the EACTS.

An International Nomenclature for Congenital Heart Surgery was officially adopted at the Annual Meeting of the EACTS in Glasgow, UK on September 6, 1999. This nomenclature was achieved following 1 year's work of the International Nomenclature and Data Base Committee for Congenital Heart Surgery of the Society of Thoracic Surgeons. This international group included members from the STS, AATS, AHA and EACTS and associated surgeons and cardiologists from United States, Canada, Australia and Europe. The Nomenclature includes a minimal data set of 21 items and lists of 150 diagnoses, 200 procedures, 32 complications and 28 extra cardiac anomalies and preoperative risk factors. It will serve as a basis for the Pediatric European Cardiac Surgical Registry (http://www.pediatric. ecsur.org). The outcome of such an International Nomenclature represents an important event for the medical community in charge of treating patients with congenital heart diseases. It will allow scientific exchanges on an international scale and promote multicenter evaluation of congenital heart surgery. Nevertheless, this Nomenclature is only the first step. Further collection of validated data at the Pediatric ECSUR Data Base requires ethical belief, time consumption and financial resources. Comparison of results, according to pathologies, across centers and countries will help define, in the future, official European standards of Quality of Care available for health care organizations, public scrutiny and governmental agencies.

Congenital Heart Surgery Nomenclature and Database Project: overview and minimum dataset.

The International Congenital Heart Surgery Nomenclature and Database Project was organized for the purpose of standardizing nomenclature and reporting strategies that would establish the foundations for an international database. Worldwide representatives met for a series of conferences, at which time, issues of nomenclature were discussed and debated. Authors were chosen to review the various congenital heart diagnoses and reflect the mediated debate that followed. Manuscripts were prepared that reviewed the appropriate extant nomenclature, made recommendations for an inclusive rather than an exclusive method of reporting, and determined a hierarchical database scheme that would allow several levels of reporting based on the data input. This manuscript outlines two datasets for an international congenital heart surgery database, a minimum dataset and a comprehensive dataset. The comprehensive dataset includes all the imagined variables, in a hierarchical scheme, which are detailed enough to generate risk stratification analyses. The minimum dataset will include data points that would create an essential dataset, which would be mandatory for data sharing and would lend itself to basic interpretation of trends. The minimum dataset has four drop-down menus for short lists of: (1) noncardiac abnormalities/general preoperative risk factors, (2) diagnoses, (3) procedures, and (4) complications, from which clinicians can choose for entry into the minimum dataset. There was universal agreement for these datasets and short lists by the assembled members of the Society of Thoracic Surgeons-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. The datasets and short lists were also unanimously approved by the Congenital Heart Surgery Committee of The European Association for Cardiothoracic Surgery and adopted by the European Congenital Heart Surgeons Foundation.

Congenital Heart Surgery Nomenclature and Database Project: atrial septal defect.

The extant nomenclature for atrial septal defect (ASD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: ventricular septal defect.

The extant nomenclature for ventricular septal defect (VSD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Four basic VSD types are described: Subarterial, Perimembranous, Inlet, and Muscular. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analysis. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: atrioventricular canal defect.

The extant nomenclature for atrioventricular (AV) canal/atrioventricular septal defect is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. The three general categories are: partial AV canal (ostium primum defect), transitional (intermediate) AV canal, and complete AV canal. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: aortopulmonary window.

The extant nomenclature for aortopulmonary window (AP window) and pulmonary artery origin from ascending aorta (hemitruncus) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: double outlet right ventricle.

Double outlet right ventricle (DORV) is a type of ventriculoarterial connection in which both great vessels arise entirely or predominantly from the right ventricle. Although the presence of aortic-mitral discontinuity and bilateral coni are important descriptors, they should not serve as absolute prerequisites for the diagnosis of DORV. The morphology of DORV is encompassed by a careful description of the ventricular septal defect (VSD) with its relationship to the semilunar valves, the great artery relationships to each other, the coronary artery anatomy, the presence or absence of pulmonary outflow tract obstruction (POTO) and aortic outflow tract obstruction (AOTO), the tricuspid-pulmonary annular distance, and the presence or absence of associated cardiac lesions. The preferred surgical treatment involves the connection of the left ventricle to the systemic circulation by an intraventricular tunnel repair connecting the VSD to the systemic semilunar valve. This ideal surgical therapy is not always possible due to the presence of confounding anatomical barriers. A multitude of alternative surgical procedures has been devised to accommodate these more complex situations. A framework for the development of the DORV module for a pediatric cardiac surgical database is proposed.

Congenital Heart Surgery Nomenclature and Database Project: arrhythmias.

This discussion of arrhythmia terminology attempts to classify rhythm disorders for which surgical therapy may be necessary. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery, for the purpose of establishing a unified reporting system. Efforts were made to include all relevant nomenclature categories, using synonyms where appropriate. Extant surgical ablative procedures, detailed methods of pacemaker insertion, and AICD technology are discussed. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented, which will allow for data sharing and will lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Heparin-coated cardiopulmonary bypass circuit: clinical effects in pediatric cardiac surgery.

OBJECTIVES: Heparin-coated cardiopulmonary bypass (CPB) circuits have been reported to reduce complement activation and the inflammatory response associated with CPB. We retrospectively compared patients utilizing heparin-coated perfusion circuits with those using noncoated circuits to determine the clinical effects of the different circuits in pediatric cardiac surgery. METHODS: Between July 1995 and July 1997, 203 patients weighing < 10 kg underwent cardiac surgery, 153 patients using heparin-coated bypass circuits and 50 patients using noncoated circuits. The 50 patients operated on with the noncoated circuit (Group N) were matched to 100 patients operated on with coated circuits (Group H) in age, weight, and type of procedure. Urine output during bypass, blood products used after bypass, postoperative ventilation days, hospital stay, morbidity, and mortality were compared between these groups. RESULTS: Body weight, perfusion time, and procedure time were not different between the two groups. Urine output during bypass was notably greater in Group H than in Group N (11.3 +/- 10.5 mL/kg per hour vs 4.8 +/- 3.1 mL/kg per hour, respectively, p < 0.0001). Postoperative mechanical ventilation markedly decreased in Group H (Group H vs N = 2.8 +/- 2.7 days vs 5.1 +/- 7.5 days, respectively, p < 0.05). Red blood cell usage, hospital stay, morbidity, and mortality were not statistically different, although there was a tendency toward decreased transfusion of red cell and platelets in Group H (Group H vs N = 61.2 +/- 121.1 mL/kg vs 102.0 +/- 176.7 mL/kg, respectively, in red cell, p = 0.15; and Group H vs N = 7.9 +/- 13.7 mL/kg vs 13.2 +/- 24.5 mL/kg, respectively, in platelets, p = 0.16). CONCLUSIONS: Patients operated on with the use of heparin-coated circuits had increased urine output during bypass and required less time postoperatively on the ventilator. These results suggest a reduction in the acute inflammatory response, capillary leakage, and overall systemic edema. We now routinely use coated circuits on all pediatric pump cases.

Tracheal allograft reconstruction: the total North American and worldwide pediatric experiences.

BACKGROUND: We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. METHODS: The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. RESULTS: In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. CONCLUSIONS: Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.

Video-assisted thoracoscopic surgery for patent ductus arteriosus in low birth weight neonates and infants.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been assuming an expanded role in the management of cardiothoracic disease. As instrumentation and experience increase, VATS is being applied to treat smaller patients. We report our experience with 34 low birth weight infants undergoing VATS interruption of patent ductus arteriosus (PDA). METHODS: VATS allows PDA interruption without the muscle cutting or rib spreading of a standard thoracotomy. Four small, 3-mm incisions are made along the line of a potential thoracotomy incision. Ports placed through these incisions admit endoscopic instruments, a camera, and a vascular clip applier. RESULTS: Median age at surgery was 15.5 days (range: 1-44 days). Median weight at surgery was 930 g (range: 575-2500 g). Twenty patients weighed <1 kg, and 13 weighed <750 g. All patients had congestive heart failure and had either failed indomethacin therapy or had contraindications to indomethacin. Median surgical time was 60 minutes (range: 31-171 minutes). Echocardiography documented elimination of ductal flow in all patients. Operative mortality was zero. Four patients (4/34 = 12%) required conversion to open thoracotomy: 1 because of difficult exposure, 1 because of pulmonary dysfunction and anasarca, 1 because of a large 1-cm duct, and 1 because of coagulopathy and poor pulmonary compliance. Two patients died before discharge: 1 patient (surgical weight: 605 g) died on postoperative day 2 because of intracranial hemorrhage, and 1 patient (surgical weight: 1725 g) died on postoperative day 88 because of multiple system organ failure. Follow-up has demonstrated no PDA murmur in any patient, but echocardiography revealed trace ductal flow in 2 patients. CONCLUSIONS: VATS offers a minimally traumatic, safe, and effective technique for PDA interruption in low birth weight neonates and infants.

Video-assisted cardioscopy for left ventricular thrombectomy in a child.

Left ventricular thrombus is a complication of myocardial infarction, ventricular aneurysm, cardiomyopathy, and myocarditis. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and aneurysm formation. We describe a case of left ventricular thrombus with systemic embolization in a patient with myocarditis. Video-assisted cardioscopy allowed visualization and removal of the thrombus via an aortotomy, thereby avoiding a left ventriculotomy.

Transcatheter closure of an extracardiac Fontan fenestration.

As the extracardiac Fontan operation evolves, a reliable method for creating and subsequently closing communications between the systemic and pulmonary venous chambers would be useful. We describe a surgical technique for creating this "fenestration" and a complementary transcatheter technique that allows safe and reliable closure of these communications regardless of size and position.

The unenlarged lymph nodes of HIV-1-infected, asymptomatic patients with high CD4 T cell counts are sites for virus replication and CD4 T cell proliferation. The impact of highly active antiretroviral therapy.

The efficacy of triple drug therapy for HIV-1 infection encourages its early use to prevent damage to the immune system. We monitored the effects of such therapy on 12 patients with 14-75-mo histories of minimal disease, i.e., CD4+ counts constantly >500/microl and little or no lymph node enlargement. In this way, we could first determine the extent of viral replication and immunoarchitectural changes in unenlarged nodes early in disease, and second follow the response to triple therapy in plasma and lymphoid tissue in tandem. As is known for lymph nodes with more advanced disease, the germinal centers showed productively infected T cells, i.e., CD4+CD1a-CD68- cells labeling intensely for HIV-1 RNA after in situ hybridization. The unenlarged nodes also showed extensive HIV-1 RNA retention on a well-preserved, follicular dendritic cell (FDC) network, and the follicles were abnormal. There were numerous CD8+ cells, many expressing TIA-1 granule antigen. Also, in contrast to normal follicles, CD4+ T cell proliferation was active, with marked increases in the number of cycling, Ki-67+CD4+CD45R0+ cells. After 28 d and 3 mo of therapy, productively infected T cells decreased dramatically and often were not apparent. The labeling of the FDC network for viral RNA also decreased, but not for gag protein. We conclude that HIV-1 replicates and accumulates in lymphoid organs before damage of the immune system, that at this stage of disease de novo production of T cells occurs in the lymphoid tissue, and that the infection is sensitive to triple drug therapy in both plasma and lymph nodes.