Mapping of quantitative trait loci for fire blight resistance in the apple cultivars 'Florina' and 'Nova Easygro'.

Fire blight is a devastating bacterial disease of rosaceous plants. Its damage to apple production is a major concern, since no existing control option has proven to be completely effective. Some commercial apple varieties, such as 'Florina' and 'Nova Easygro', exhibit a consistent level of resistance to fire blight. In this study, we used an F1 progeny of 'Florina' × 'Nova Easygro' to build parental genetic maps and identify quantitative trait loci (QTLs) related to fire blight resistance. Linkage maps were constructed using a set of microsatellites and enriched with amplified fragment length polymorphism (AFLP) markers. In parallel, progeny plants were artificially inoculated with Erwinia amylovora strain CFBP 1430 in a quarantine glasshouse. Shoot length measured 7 days after inoculation (DAI) and lesion length measured 7 and 14 DAI were used to calculate the lesion length as a percentage of the shoot length (PLL1 and PLL2, respectively). Percent lesion length data were log10-transformed (log10(PLL)) and used to perform the Kruskal-Wallis test, interval mapping (IM), and multiple QTL mapping (MQM). Two significant fire blight resistance QTLs were detected in 'Florina'. One QTL was mapped on linkage group 10 by IM and MQM; it explained 17.9% and 15.3% of the phenotypic variation by MQM with log10(PLL1) and log10(PLL2) data, respectively. A second QTL was identified on linkage group 5 by MQM with log10(PLL2) data; it explained 10.1% of the phenotypic variation. Genotyping the plants of 'Florina' pedigree with the microsatellites flanking the QTLs showed that the QTLs on linkage groups 5 and 10 were inherited from 'Jonathan' and 'Starking' (a 'Red Delicious' sport mutation), respectively. Other putative QTLs (defined as QTLs with LOD scores above the chromosomal threshold and below the genome-wide threshold) were detected by IM on linkage groups 5 and 9 of 'Nova Easygro'.

[Are mortality indicators acceptable indicators for the quality of health care?]. / Les indicateurs de mortalité sont-ils de bons indicateurs de qualité des soins?

IMPORTANCE OF PUBLISHING MORTALITY RATES: Mortality rates for certain interventions or disease states have been used over the last decade as indicators of the quality of care provided by a given hospital, unit or, medical team. If published, these rates would be a useful tool for decision makers in the process of fund allocations, for public information, and for promoting improved care in hospitals or units with a low classification. METHODOLOGICAL LIMITATIONS: It is difficult to adjust an indicator of mortality to disease-related risk factors and any modification of this adjustment can have major consequences on the validity of subsequent comparisons. The differences in mortality observed between hospitals and physicians can reflect not only differences in quality of care but also differences in approaches to disease-related risk factors, therapeutic choices, or coding practices. The lack of statistical power is a major limiting factor in interpreting differences in mortality rates. To evidence a statistically significant difference in mortality between two hospitals whose rates are respectively 0.5% and 1% (for example in total hip replacement patients), it would be necessary to include 4673 patients, a number which would correspond to 20 years data for a hospital performing 230 interventions per year. Consequently, the number of interventions performed in the most active hospitals would not be sufficient to make such comparisons. LIMITATIONS AND COUNTER EFFECTS: Some studies have demonstrated that the publication of mortality rates does not have a major influence on patients' decisions nor on physicians' choice of a referral hospital. It would have no effect on improving health care quality of the institutions cited. One the contrary, certain counter effects have been observed: modification in patient recruitment, higher-risk patients being referred to hospitals with unpublished mortality rates. For many authors, procedure indicators are more pertinent than outcome indicators for detecting differences in health care quality between different care structures.

[Post-traumatic false aneurysm of the suprarenal abdominal aorta. Original surgical technique]. / Faux anévrysme post-traumatique de l'aorte abdominale sus-rénale. Technique opératoire originale.

Post-traumatic abdominal aorta false aneurysm is rare, especially in the supra-renal segment. We present the case of a patient which severe respiratory failure who could not be sterno-phreno-laparotomized: we propose an original operative technique of exclusion of the false aneurysm by a limited incision preserving the diaphragm, with circulatory arrest and profound hypothermia, without aortic clamping, under cardiopulmonary bypass. We discuss the other surgical possibilities and propose our technique for special indications.

[Tumors of the heart in newborn infants and infants. Apropos of 5 cases]. / Tumeurs du coeur du nouveau-né et du nourrisson. A propos de cinq cas.

Between February 1985 and March 1987, 5 children underwent resection of primary cardiac neoplasms, 3 of them in the first days of life and 2 before the age of 6 months. Routine echocardiographic follow-up of pregnancies allowed detection of cardiac tumors in 2 foetuses 30 and 36 weeks old. In 3 children the diagnosis was suspected by the discovery of cardiac murmur or congestive heart failure. The first case was a hemangioma, originating from outside the left ventricular wall, and was resected without cardiopulmonary bypass (CPBP). The other case was a pseudomyxoma, spreading extensively in to the right atrium. The third case was a rhabdomyoma arising from the pulmonary infundibulum with clinical manifestations of tuberous sclerosis. The last two patients had intraseptal lesions, just above the aortic valve; complete resection was therefore impossible, particularly in one patient with multiple tumors. There was one death related to congestive heart failure. The remaining four survivors were followed up for an average of 18.4 months (+/- 12.9) and all were in functional class I. Echocardiographic follow-up showed evidence of a residual subaortic lesion in one asymptomatic patient.

[Heart tumors in newborn infants and infants. Apropos of 5 cases]. / Tumeurs du coeur du nouveau-né et du nourrisson. A propos de cinq cas.

Between February 1985 and March 1987, 5 children underwent resection of primary cardiac neoplasms, 3 of them in the first days of life and 2 before the age of 6 months. Routine echocardiographic follow-up of pregnancies allowed detection of cardiac tumors in 2 foetuses 30 and 36 weeks old. In 3 children the diagnosis was suspected by the discovery of cardiac murmur or congestive heart failure. The first case was an hemangioma, originating from outside of the left ventricular wall, which could be resected without cardiopulmonary bypass (CPBP). The other case was a pseudomyxoma, spreading extensively inside the right atrium. The third case was a rhabdomyoma arising from the pulmonary infundibulum with clinical manifestations of tuberous sclerosis. The last two patients had intraseptal lesions, just above the aortic valve; complete resection was therefore impossible, particularly in one patient with multiple tumors. There was one death related to congestive heart failure. The remaining four survivors were followed up for an average of 18.4 months (+/- 12.9) and all were in functional class I. Echocardiographic follow-up showed evidence of a residual subaortic lesion in one asymptomatic patient.

[Hancock pericardial prosthesis. Intrinsic dysfunctions]. / Prothèses de Hancock péricardiques. Dysfonctions intrinsèques.

The frequency of primary dysfunction of 432 Hancock pericardial bioprosthesis was evaluated during a mean follow-up period of 53.1 months per patient. This frequency was 3.20% valve-year in mitral valve prosthesis and 0.92% valve-year in aortic valve prosthesis. Only one case of calcification was noted. Dysfunction was usually due to tearing of one or several pericardial cusps (25 cases), occasionally to tissue retraction (4 cases). Pathological examination of the explanted valves showed fibrin formation followed by organization into fibrous tissue in the host, retracting or fragilizing the pericardial valvular tissue. A preliminary study of the same group had led to discontinuation of Hancock prosthesis. The long follow-up period makes it possible to compare the results obtained with those of pericardial prosthesis of the same generation, to stress the need for echocardiographic monitoring of the implanted valves and to hope that new techniques of pericardial valve fitting will improve the mechanical reliability of prosthesis which, from the point of view of thrombogenesis and haemodynamics, have unquestionable advantages.

Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis.

Between 1980 and 1986, 80 infants (less than or equal to 3 months old) with symptomatic aortic coarctation and associated severe tubular hypoplasia of the transverse aortic arch underwent surgical treatment. Extended end-to-end aortic arch anastomosis was used in an attempt to correct both the isthmic stenosis and the hypoplasia of the transverse arch. After complete excision of the coarctation tissue, a long incision was made in the inferior aspect of the aortic arch, which was then anastomosed to the obliquely trimmed distal aorta. Pure coarctation was present in 17 patients (group I); 24 infants had an additional ventricular septal defect (group II), and 39 patients had associated complex heart disease (group III). The overall early mortality rate was 26% (confidence limits 21% to 32%) (18% in group I, 17% in group II, and 36% in group III). The early risk declined with time and was 18% (confidence limits 12% to 26%) for the last 2 years (seven deaths in 39 patients). Follow-up was 100% for a mean of 19 months. Actuarial survival rate at 3 years was 82% for group I, 78% for group II, and 32% for group III. Recurrent coarctation (gradient greater than or equal to 20 mm Hg) occurred in six operative survivors (10%, confidence limits 6% to 16%) and necessitated reoperation in three. Freedom from recoarctation at 4 years was 88%. Because extended end-to-end aortic arch anastomosis provides adequate correction of the aortic obstruction and entails a low risk of restenosis, it is our procedure of choice in infants with coarctation and severe hypoplasia of the aortic arch.

[Replacement of the ascending aorta with reimplantation of coronary vessels. Apropos of 81 cases]. / Remplacement de l'aorte ascendante avec réimplantation des coronaires. A propos de 81 observations.

Between 1973 and 1985, 81 patients underwent Bentall's operation. 90 p. 100 of the patients had cystic medionecrosis, but only 24 showed signs of Marfan's syndrome. It must be noted that 12 patients were reoperation cases, 18 were operated upon in an emergency for tamponade (stage V) on acute dissection, and 7 had lesions that involved the aortic arch. The operative procedure was that described by Bentall; Cabrol's modification was used in only 26 patients. The most recent improvements concerned myocardial and (in case of aortic involvement) cerebral protection with an autonomous perfusion of blood at very low temperature. Mortality was low in patients with annulo-aortic ectasia (1 death in 53 cases; 1.8 p. 100) and rose to 34.5 p. 100 (33.3 p. 100 in reoperation cases) in patients with chronic dissection. Evaluation of mortality by stage showed virtually no risk in stages I and II, whereas 4 of the 9 stage IV patients died within the first post-operative month. Late mortality with a mean follow-up of 4 years was 14.2 p. 100; 2 of the 10 deaths were accidental, and 4 of the remaining 8 deaths were due to the anticoagulant therapy (death was precipitated in 2 cases by the presence of a cerebral aneurysm). No case of systemic embolism was observed, and the authors raise the question of whether long-term anticoagulant therapy should be abandoned. None of the patients who underwent Bentall's operation were reoperated upon, whereas 7 out of the 23 patients who had had supracoronary aortic replacement before 1976 had been reoperated upon within a few years.(ABSTRACT TRUNCATED AT 250 WORDS)

Coarctation of the aorta in infants: which operation?

In this series, 178 infants (age, less than or equal to 3 months old) underwent repair of aortic coarctation. Pure coarctation was present in 63 patients (Group 1), 47 infants had additional ventricular septal defects (Group 2), and 68 patients had associated complex heart disease (Group 3). Subclavian flap angioplasty was used in 26 patients, limited resection and end-to-end anastomosis in 45 patients, extended resection and end-to-end anastomosis in 99 patients, and miscellaneous procedures in 8 infants. The early mortality was 8% for the first group, 11% for the second group, and 37% for the third group (p less than 0.001). Mean follow-up was 32 months and included 97% of patients. Actuarial survival at five years was 90% for the first group, 84% for the second group, and 40% for the third group. Recoarctation occurred in 15 operative survivors (11%); 7 necessitated reoperation. Freedom from recoarctation at five years was 89% after subclavian flap angioplasty, 81% after end-to-end anastomosis, and 86% following extended resection and end-to-end anastomosis. Early mortality and late results were not influenced by the type of coarctation repair but were determined by the clinical status and the presence of associated major cardiac anomalies. These results suggest that the surgical procedure should be individualized for each infant to optimize the aortic anatomy.

[Emergency surgical repair of acute aortic arch dissection. Apropos of 14 cases]. / Réparation chirurgicale en urgence des dissections aiguës de la crosse aortique. A propos de 14 cas.

Among 70 patients operated upon for acute dissection of the ascending aorta between 1977 and 1984, 14 (age range 40-72 years) benefited from emergency aortic arch repair motivated by the presence in, or extension to, this segment of the portal of entry, or by lesions of the supra-aortic main vessels. The operation was performed under cardiopulmonary bypass in all cases. Cerebral protection was ensured in 9 patients by deep hypothermia alone or with circulatory arrest for a mean period of 5 minutes (7 cases), and in 5 patients by continuous brain perfusion (carotid blood flow 4 ml/kg/min; perfusion pressure 70 mmHg). Repair consisted of ascending aorta replacement combined with gluing of the arch whenever possible, or bevelled resection in the concavity of the arch, or complete aortic arch replacement with reimplantation of the cervico-cerebral vessels when necessary. In every case the gelatin-resorcin-formalin glue was used to reinforce the aortic wall or the areas with sutures. Operative mortality was nil. Hospital mortality was 28.5%. In patients operated upon under deep hypothermia alone or associated with circulatory arrest the main complications were neurological (4 cases) and respiratory (3 cases) disorders; these were responsible for the death of 3 patients. A fourth patient died of mediastinitis. No neurological or respiratory complication occurred in patients who had brain perfusion. The mean follow-up period was 37 months (range 7-84 months). Late mortality was nil. All but one patient (sequelae of paraplegia) are in excellent clinical condition. Post-operative angiography alone or combined with computerized tomography showed satisfactory blood distribution in all cases and no aneurysm formation on the dissected aorta despite a persistent false lumen.

[Aneurysm of the aortic arch. Surgical therapy. 60 cases]. / Anévrysmes de la crosse aortique. Traitement chirurgical. Soixante observations.

Sixty patients with aortic arch aneurysm have been operated upon at the Foch Medico-Surgical Centre between 1964 and 1984. This period can be subdivided into: January, 1964 to December, 1975 (24 cases) and January, 1976 to April, 1984 (36 cases). The technique used (closure by patch or segmental replacement prosthesis) depended on the type of lesion encountered. In most cases, the cardiopulmonary bypass was between the femoral artery and the right atrium. After experimenting with different methods, we now protect the brain by selective cold blood carotid perfusion, using independent circuit and heat-exchanger. Operative mortality was 12% in series I (1964-1975) and 0% in series II (1975-1984) patients. Hospital mortality was 25% in series I and 13% in series II patients. The improvements obtained during the last few years, using cold blood carotid perfusion and circulatory arrest in the lower half of the body, have made it possible to perform open distal anastomoses. This method ensures excellent brain protection and short cardiopulmonary bypass period.

[Acute dissection of the aorta in 1986. Proposal for a new anatomopathological classification]. / La dissection aiguë de l'aorte en 1986. Proposition d'une nouvelle classification anatomo-pathologique.

Acute dissection of the aorta is a rare disease which, when left untreated, has a disastrous prognosis. Two aetiological factors are essential: acquired or congenital fragility of the aortic elastic tissue, and arterial hypertension. The condition must be diagnosed as early as possible to avoid a fatal outcome: it is a surgical emergency. The clinical diagnosis rests on a history of migrating pain and on the presence of signs of ischaemia in a vascular territory. It is confirmed by complementary investigations, chiefly angiography. Acute dissection of the ascending aorta is treated by surgery: the ascending segment is resected, the distal cylindres are recoupled to close the portal of entry, and the aortic regurgitation is treated by valvuloplasty or aortic valve replacement. The introduction of the GRF biological glue has considerably improved the per-operative prognosis and lowered the hospital mortality to 10%. Long-term post-operative follow-up of the patient is crucial, since iterative dissection and formation of aneurysms are not exceptional, especially in patients with Marfan's syndrome.

Late results after left-sided cardiac valve replacement in children.

Selection of types of cardiac valve substitutes for children remains controversial. Between 1976 and 1984, 166 children, 15 years of age or younger, underwent aortic (N = 53) or mitral valve replacement (N = 90) or both (N = 23). Biological prostheses were used in 84 patients and mechanical prostheses in 71; both a mitral bioprosthesis and an aortic mechanical valve were used in 11 patients. The overall early mortality was 9%. Mean follow-up intervals were 4.1 years for the bioprosthesis group, 3.3 years for the mechanical valve group, and 3.5 years for the group receiving both. The 7 year survival rates (+/- standard error) were 63% +/- 6% in the bioprosthesis group and 70% +/- 7% in the mechanical valve group (p = NS). After aortic valve replacement the 7 year survival rates were 66% +/- 14% (bioprosthesis group) and 77% +/- 9% (mechanical valve group) (p = NS); after mitral valve replacement the rates were 65% +/- 7% (bioprosthesis group) and 54% +/- 17% (mechanical valve group) (p = NS). The incidence of thromboembolic events was 0.6% +/- 0.4% per patient-year in the bioprosthesis group (none after aortic valve replacement, 0.8% +/- 0.6% per patient-year after mitral valve replacement) and 1.4% +/- 0.8% per patient-year in the mechanical valve group (0.7% +/- 0.7% per patient-year after aortic valve replacement, 4.0% +/- 2.8% per patient-year after mitral valve replacement) (p = NS). The linearized rates of reoperation were 10.4% +/- 1.8% per patient-year (bioprosthesis group) and 2.3% +/- 1.0% per patient-year (mechanical valve group) (p less than 0.001). The 7 year probability rates of freedom from all valve-related complications were 43% +/- 6% in the bioprosthesis group and 86% +/- 4% in the mechanical valve group (p less than 0.001). In the aortic position, a mechanical adult-sized prosthesis can always be implanted, and satisfactory long-term results can be anticipated. In the systemic atrioventricular position, the results are less than satisfactory with either type of prosthesis; every effort should be made to preserve the natural valve of the child.

[A new technic of cerebral protection. Surgery of the aortic arch]. / Nouvelle technique de protection cérébrale. Chirurgie de la crosse aortique.

A new technique of cerebral protection during surgery of the aortic arch is described. It is based on electric perfusion of the carotid arteries with low temperature (6 degrees-10 degrees) blood. This requires the adjunction on the cardiopulmonary bypass of an independent heat-exchanger. The first results obtained in 6 patients showed perfect protection of the brain throughout the surgical procedure, with early recovery from anaesthesia and complete absence of neurological sequelae. There were no deaths.

[Transjejunal subpyelic cutaneous ureterostomy. A solution to upper urinary diversion in pelvic oncology]. / L'urétérostomie cutanée transjéjunale sous-pyélique. Une solution à la dérivation haute des urines en carcinologie pelvienne.

In the operation described the second jejunal loop is isolated through an horizontal incision linking the tips of the 12 th ribs. The ends of the loop are then anastomosed with the sub-pyelic ureters and the resulting V-shaped conduit is brought to the skin. The main complication is a salt-deficiency syndrome due to the physiology of the isolated jejunal loop. The loss of salt may be troublesome in patients with pre-existing renal insufficiency. This syndrome is corrected by oral administration of sodium chloride.