The effectiveness of educational interventions in university training on hospital hygiene: results of action research.

BACKGROUND: The Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health promoted and conducted a study on teaching hospital hygiene, with particular reference to the prevention and control of healthcare-associated infections, with the aim of developing effective educational material starting from the results collected. MATERIAL AND METHODS: First of all, a survey was carried out, targeting lecturers in hospital hygiene, with the purpose of investigating their perceptions regarding this issue. The available scientific literature was also reviewed in order to identify effective educational/teaching strategies for the prevention of healthcare-associated infections, so that valid training interventions could be subsequently developed. Finally, a trial-training intervention was implemented, and specific audio-visual teaching material was also tested. RESULTS: The overall response rate to the survey was 42%, with good country-wide representativeness. The level of awareness of hospital hygiene issues by students resulted higher among trainee nurses (65%) than among medical students (44%). The teaching staff identified alternative educational methodologies to substitute the classical lecture (e.g.: case discussions) and, in most cases, the alternative solution appeared to be preferable. The teaching of hospital hygiene was better integrated with other disciplines and professional training activities in the degree courses for nurses than in those for doctors; the total number of hours assigned to such teaching was variable. The literature review highlighted that various educational approaches are used. The most common are presentations or lectures, but videos, posters, questionnaires and e-learning strategies are also used. Combining different instruments when designing an educational programme has proven to be an effective strategy. The training activity tested was positively evaluated by the participants; the possibility of multidisciplinary exchange of knowledge was particularly appreciated. CONCLUSION: Having considered the issue of teaching hospital hygiene from the points of view of the different protagonists involved (educators and students), this enabled us to develop useful training material and a proposal for a shared educational intervention. The subject of hospital hygiene, in particular the one related to the prevention of healthcare-associated infections, is addressed in various courses and with different modalities; it is, therefore, important to standardize course contents and teaching methods, in order to facilitate multidisciplinary debate, especially starting from case studies.

Bimodal regulation of p21(waf1) protein as function of DNA damage levels.

Human p21(Waf1) protein is well known for being transcriptionally induced by p53 and activating the cell cycle checkpoint arrest in response to DNA breaks. Here we report that p21(Waf1) protein undergoes a bimodal regulation, being upregulated in response to low doses of DNA damage but rapidly and transiently degraded in response to high doses of DNA lesions. Responsible for this degradation is the checkpoint kinase Chk1, which phosphorylates p21(Waf1) on T145 and S146 residues and induces its proteasome-dependent proteolysis. The initial p21(Waf1) degradation is then counteracted by the ATM-Chk2 pathway, which promotes the p53-dependent accumulation of p21(Waf1) at any dose of damage. We also found that p21(Waf1) ablation favors the activation of an apoptotic program to eliminate otherwise irreparable cells. These findings support a model in which in human cells a balance between ATM-Chk2-p53 and the ATR-Chk1 pathways modulates p21(Waf1) protein levels in relation to cytostatic and cytotoxic doses of DNA damage.

Outlining job descriptions of the health professions for preventive care: an exploratory study at the Local Health Authority of Milan, Italy.

BACKGROUND: Job descriptions are detailed descriptions of particular job positions; they are utilized to select and evaluate the personnel, but also to assess the professionals' educational needs; in fact, job descriptions identify which tasks the employee is expected to perform and his/her required characteristics. The aim of this study was to explore suitable methodologies to analyze the job positions in the health professional field, to outline specific job descriptions. More specifically, we intended to study how to outline the job descriptions of the health professions for preventive care (Public Health Nurses, PHN, and Occupational and Environmental Health Officers, OEHO ) employed at the Local Health Authority (LHA) of Milan, in order to contribute to their educational needs assessment. METHODS: Data were collected in 2012 from a purposive sample of 29 professionals belonging to the population under study (PHN and OEHO employed at the LHA of Milan), and from other 7 healthcare professionals working in the staff (totally 36 participants), through two qualitative methods: focus groups and participant field observations. We used two methods of data gathering to attain triangulation, in order to increase the validity of the results. A thematic analysis was performed by two researchers on focus groups transcriptions and filed notes. RESULTS: A list of 26 activities performed by participants in different contexts of the LHA emerged in the focus groups; ten of those activities were studied in the field through participant observations, which confirmed what informants said in the focus groups. Concerning the methodology for data gathering to outline job descriptions, participants appreciated focus groups, since they gave them the opportunity to reflect on the activities performed at the LHA, highlighting critical aspects of those activities and therefore their educational needs. Participant field observations, conducted by a researcher belonging to the health professions for preventive care, did not encounter any resistance, but were less appreciated by participants than focus groups. From the researcher's point of view, the field observations were less efficient than focus groups. CONCLUSIONS: Focus groups have proven to be a valid tool to outline job descriptions of health professions for preventive care, since they are perceived not only as a method for data gathering, but also as a means to identify their educational needs. When triangulated with field observations, data gathered through focus groups enhanced their validity, but participant observations proved to be scarcely efficient. Further research is needed on instruments that allow data gathering on job descriptions to be triangulated with focus groups, such as questionnaires.

'My wig has been my journey's companion': perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia.

This study explored the perceived effects of an aesthetic care/wig programme for Italian women suffering from chemotherapy-induced alopecia. Despite advances in the treatment of many side effects of chemotherapy, alopecia remains difficult to resolve. Literature suggests that patients' reactions to alopecia and camouflaging strategies depend on their gender, individual characteristics, social context, and culture. A qualitative study was designed involving 20 patients from Sicily (Italy), who participated in an aesthetic care programme. Data were collected through semi-structured interviews, and an Interpretative Phenomenological Analysis was conducted on transcriptions. Our findings showed that, even if expected, alopecia is experienced as a traumatic event that challenges a woman's femininity, as reported by many other enquiries. Diverging from other studies, the wig is perceived as very helpful, since it camouflages baldness and reduces the 'sick aspect' related to alopecia. Patients consider their wig to be a 'friend', and it appears that through the aesthetic care programme they received support they otherwise would not have sought. We conclude that aesthetic care/wig programmes can help women affected by alopecia to cope with cancer 'stigma', especially in those rural contexts where psychosocial programmes are not frequently embraced by patients due to environmental and cultural barriers.

Long-term results of catheter-based treatment of pulmonary atresia and intact ventricular septum.

OBJECTIVE: To review the outcome of patients with pulmonary atresia with intact ventricular septum after interventional perforation of the pulmonary valve, to assess the capability of this procedure to avoid neonatal or late intervention and to obtain a long-term biventricular repair. DESIGN: Retrospective interventional study and clinical follow-up study. SETTING: Tertiary referral centre. PATIENT POPULATION: Between November 1994 and December 2007, 40 neonates underwent radiofrequency perforation. Median age at pulmonary valvotomy was 28 hours (range 1-147 hours) and median weight was 2925 g (range 1900-4400 g). MAIN OUTCOME MEASURES: Procedural success and complication rates; early-term and long-term follow-up results. RESULTS: The procedure was successful in 39 patients but 16 of them needed neonatal surgery. The overall mortality was 7.5%. At a median follow-up of 82 months, four patients underwent a bidirectional Glenn procedure, whereas all the other patients achieved a biventricular circulation without any further intervention in 19 of them. Patients who died or needed additional intervention with or without biventricular circulation failure had a higher incidence of bipartite right ventricular (65% vs 15.8% of those not needing additional intervention; p = 0.004) and a lower median tricuspid Z value (-2 (range -3.5 to 1) vs -0.5 (range -2 to 1); p = 0.004)). CONCLUSIONS: The results confirm that percutaneous interventional perforation is an effective first-stage procedure in patients with pulmonary atresia with intact ventricular septum. The right heart appeared to be adequate to maintain a long-term biventricular circulation in the large majority of cases.

Clinical evaluation of oxidative stress and myocardial reperfusion injury in pediatric cardiac surgery.

BACKGROUND: To evaluate oxidative stress and myocardial damage after aortic crossclamping release (ACCR) during cardio pulmonary bypass (CPB) in children two parameters were investigated: total glutathione (GSH) and its oxidoreductive reactions (GSH/GSSG) as expression of oxidative stress, and plasmatic turnover of myocardial taurine (TAU) as expression of cell damage. METHODS: The study was divided in two periods: 1) first period: analysis of oxidative stress and myocardial damage in 18 children. 2) Second period: evaluation of myocardial cell protection by controlled anterograde low oxygen warm reperfusion (ALOWR) before declamping. Twenty-one children were divided in two groups: not receiving (Group 1, 9 patients) and receiving (Group 2, 12 patients) ALOWR. RESULTS: In the first period GSH values increased significantly after onset of mechanical ventilation (MV) in vein, after CPB start in artery and after ACCR in coronary sinus. Moreover TAU turnover in aortic and coronary sinus blood increased significantly after ACCR. In the second period, Group 2 showed a lower oxidative stress after ACCR, while no differences were observed in TAU turnover. CONCLUSIONS: 1) Assessment of TAU and GSH levels can be considered a good method to clinically evaluate myocardial injury during cardiac surgery. 2) MV and CPB can induce oxidative stress before aortic clamping and can decrease the physiologic scavengers. Therefore, to prevent that depletion, the strategy of these techniques must be adapted to the patient and to his cardiac disease. 3) Intramyocardial TAU turnover is not significantly modified by the reperfusion technique. 4) ALOWR can reduce myocardial oxidative stress and can improve heart recovery after the cardioplegic arrest.

[Circulation support in left thoracotomy for descending thoracic aorta diseases in pediatric patients]. / L'assistenza circolatoria in toracotomia sinistra nella patologia dell'aorta toracica discendente nel paziente pediatrico.

BACKGROUND: Complications of surgery of the descending thoracic aorta could include neurological problems such as paraparesis and paraplegia. Intestinal ischemia and acute renal failure could occur, too. During the cross-clamping time, the perfusion of the distal aorta by means of extracorporeal circulatory assistance can be useful to protect the spinal cord and the splanchnic organs and to reduce the incidence of these untoward events. The aim of this study was to verify the efficacy and suitability of this type of circulatory assistance in a pediatric age group. METHODS: From January 1996 to March 2000, in the Pediatric Cardiac Surgery Department of the Gaslini Institute (Genoa, Italy), 6 patients (mean age 39 months, mean weight 14.4 kg) were treated using extracorporeal circulatory assistance through the left thoracotomy. Indications for surgery included the removal of a migrated device previously inserted in order to close a patent ductus arteriosus in 1 patient, recurrent coarctation in 2 patients, and native coarctation with a poor collateral circulation in 3 patients. RESULTS: The early and late mortality rates as well as the morbidity rates (both neurological and splanchnic) were nil. CONCLUSIONS: Extracorporeal circulatory assistance can be helpful in pediatric patients and it can prevent neurological and renal injuries in cases of a) coarctation of the aorta with a poor collateral circulation and low distal pressure (< 40 mmHg during aortic occlusion); b) recoarctation with complex anatomy; c) other pathologies requiring prolonged descending thoracic aorta cross-clamping.

Giving bad news: a GPs' narrative perspective.

The purpose of this study was to explore GPs' perspectives on giving bad news during consultations. To this end, 168 GPs were asked to recall, and record on the first page of a questionnaire, an occasion when they had given medically related bad news to a patient. The stories were analysed with a qualitative and interpretative approach. Two axes, each with a semantic polarity, were identified: a relational axis (semantic polarity: escape vs accompanying) and an ethical axis (semantic polarity: the doctor's choice vs the patient's choice). Furthermore, two main topics appeared to be common to almost all the narratives: the need to reassure the patient and the account of the doctor's emotions. Two different relational patterns appear to be described by doctors. A substantial number of GPs implicitly describe a disease- or doctor-centred consultation: in these cases the physicians refer to signs and symptoms, diagnosis and treatments; they decide for themselves whether to tell the truth or not. On the other hand, a smaller number describe consultations that could be defined as patient centred: these doctors consider that their duty of care for the individual ill person is paramount and try to respect the patient's right to decide. In both these relational patterns, GPs feel it is a fundamental professional duty to reassure the patient; furthermore, they feel the most difficult aspect is managing their own emotional responses.

Chk2 activation dependence on Nbs1 after DNA damage.

The checkpoint kinase Chk2 has a key role in delaying cell cycle progression in response to DNA damage. Upon activation by low-dose ionizing radiation (IR), which occurs in an ataxia telangiectasia mutated (ATM)-dependent manner, Chk2 can phosphorylate the mitosis-inducing phosphatase Cdc25C on an inhibitory site, blocking entry into mitosis, and p53 on a regulatory site, causing G(1) arrest. Here we show that the ATM-dependent activation of Chk2 by gamma- radiation requires Nbs1, the gene product involved in the Nijmegen breakage syndrome (NBS), a disorder that shares with AT a variety of phenotypic defects including chromosome fragility, radiosensitivity, and radioresistant DNA synthesis. Thus, whereas in normal cells Chk2 undergoes a time-dependent increased phosphorylation and induction of catalytic activity against Cdc25C, in NBS cells null for Nbs1 protein, Chk2 phosphorylation and activation are both defective. Importantly, these defects in NBS cells can be complemented by reintroduction of wild-type Nbs1, but neither by a carboxy-terminal deletion mutant of Nbs1 at amino acid 590, unable to form a complex with and to transport Mre11 and Rad50 in the nucleus, nor by an Nbs1 mutated at Ser343 (S343A), the ATM phosphorylation site. Chk2 nuclear expression is unaffected in NBS cells, hence excluding a mislocalization as the cause of failed Chk2 activation in Nbs1-null cells. Interestingly, the impaired Chk2 function in NBS cells correlates with the inability, unlike normal cells, to stop entry into mitosis immediately after irradiation, a checkpoint abnormality that can be corrected by introduction of the wild-type but not the S343A mutant form of Nbs1. Altogether, these findings underscore the crucial role of a functional Nbs1 complex in Chk2 activation and suggest that checkpoint defects in NBS cells may result from the inability to activate Chk2.

Quantitative and qualitative evaluation of blood salvaged after extracorporeal circulation (ECC) in paediatric heart surgery. Study of biochemical, morphological and structural variations of RBC after ECC and after salvaging of ECC circuit priming blood.

The salvaging of ECC circuit priming blood is essential for reducing the morbidity related to homologous blood transfusions and the importance of this technique is inversely proportionate to the age and weight of the child. In infants, the washing and centrifugation of blood not only drastically reduce the risk of contracting blood-transmitted diseases and cut management costs, but are also of considerable hemodynamic importance, producing a rapid normalization of the patient's hematocrit and hemoglobin and balancing the O2 consumption/demand ratio. The marketing of miniaturized salvagin devices with 55 ml bowls by Dideco has made possible the recovery of small quantities of blood, so as to normalise the hematic crisis and permit the application of total hemodilution in low-weight patients. The salvaged blood shows an average hematocrit of 52.7+/-9.7% (max 68.1%) and an average hemoglobin of 17.6 +/- 2.9 g/dl (max 20.7 g/dl), and maintains its structural components, osmotic resistance, concentration of intraerythrocytic hemoglobin and mean corpuscular hemoglobin all intact. Washing with isoosmotic and isoionic hydroelectrolytic solutions normalizes the ionic situation in the post-operative period and activated blood salvaging after Extracorporeal Circulation. The use of solutions without nutritional substances results however in a considerable fall in the number of enzymes in the intraerythrocytic metabolic glucide chain (G6PDH: -40.7 +/- 14.3% p<0.001), (PK: -23.8 +/- 20.5% p<0.03). This drop may be responsible for erythrocytic morphological alterations (echinocytic change) and probably for the release of hemoglobin from the red blood cells. Washing with isoionic, isoosmotic solutions containing G5% and adenine could, at least in theory, improve the quality of the salvaged blood, by normalizing the morphology and the volume of the RBC and by increasing the hematocrit.

Giant aneurysm following coil occlusion of patent ductus arteriosus.

A case is described in which a giant aneurysm developed following successful PDA coil occlusion in an infant with Marfan syndrome. This rare and severe complication brings into question the need for careful evaluation of these children before and after transcatheter occlusion.

SEL1L, the human homolog of C. elegans sel-1: refined physical mapping, gene structure and identification of polymorphic markers.

We have cloned the human full-length cDNA SEL1L, which is highly similar to the C. elegans sel-1 gene, an important negative regulator of the "notch" pathway which acts as a key regulator of the cellular proliferation and specification processes in both vertebrates and invertebrates. The SEL1L gene maps to 14q24.3-31 and here we report its fine localization by HAPPY mapping, which determines its molecular distance to microsatellite markers isolated in the region. We have found two new polymorphic (CA)n microsatellites located in the gene, and have identified the exon-intron boundaries. The gene is composed of 21 exons spanning 70 kb of genomic DNA. Human SEL1L protein exhibits a high degree of similarity compared to the mouse and nematode homologs.

[Forms and methods of tutorship in the university nursing diploma. Consensus conference in San Miniato, November 1997)]. / Figure e metodi della tutorship nel diploma universitario per l'infermiere. Consensus conference di S. Miniato (Novembre 1997).

The contribution presented is the result of a workshop with the participation of nurses, educationalists and course directors involved in the education of student nurses. The different educational experiences and organizational styles adopted in nursing schools were compared and some reflections on the role and expected competences of the nurse tutor, responsible of the theoretical and practical training of student nurses are formulated. The consensus document analyzes the implications related to the different definitions of the role of the nurse-tutor and each different role is discussed according to the theoretical model it derives from. Different educational strategies are discussed and eventually proposals on the education and educational requirements of the nurse-tutor are made.

[Closure of patent ductus arteriosus in thoracoscopy: analysis of the experience in the Gaslini Institute of Genoa]. / Chiusura del dotto arterioso persistente in toracoscopia: analisi dell'esperienza dell'istituto Gaslini di Genova.

In 1993, Laborde et al described a new surgical approach for closure of the patent ductus arteriosus (PDA), using a videoassisted technique. For the first time, videosurgery was utilized in pediatric cardiovascular surgery. The advantages of this new method are that it is minimally invasive (thoracotomy is replaced by three small holes), it reduces postoperative pain, recovery is more rapid with a shorter hospital stay and convalescence, and last but not least, it offers better aesthetic results. Between July 1994 and June 1996, we utilized the videoassisted thoracoscopic technique described by Laborde in 23 patients with PDA (age: 8 m-12 yrs, mean 45.2 m +/- 37.8; weight: 5.3-32 kg, mean 23 kg +/- 10.3). In two patients, we converted the procedure to standard thoracotomy due to anatomic problems. Echo-doppler evaluation, performed in the operating room shortly after the procedure, confirmed the complete closure of the PDA in all patients. There was neither morbidity nor mortality. The average hospital stay was four days. At a mean follow-up interval of 7.2 months (range 1-13 months), all patients showed excellent cosmetic results. We conclude that thoracoscopic closure of PDA is a valuable therapeutic option that can be used as an alternative to open-chest surgery and interventional cardiology.

[Classification of congenital heart diseases and surgical interventions in pediatric cardiology for the standardization of hospitalization records]. / Classificazione delle cardiopatie congenite e degli interventi di cardiologia e cardiochirurgia pediatrica per una codifica standardizzata della documentazione di ricovero.

The utilization of DRGs for the evaluation of hospital activity requires the availability, on a current basis, of coded in-patient records (Hospital Discharge Form, SDO) with information concerning nosology of the patient and procedures performed. Consequently, the promotion of a standardized use of ICD.9 and ICD.9.CM code systems (International Classification of Diseases, 9th Revision, and International Classification of Diseases, 9th Revision, Clinical Modification) among clinicians is necessary. The National Research Council, Council Research Hospital for Cardiology and Cardiac Surgery (CREAS-IFC-CNR) has promoted the establishment of a permanent work group for the evaluation of the activity in the field of pediatric cardiology and cardiosurgery at a national level. In co-operation with two leading institution (AO "Bambino Gesù", Rome; AO "G. Gaslini", Genoa) an in-patient survey has been promoted including an overall revision of the ICD.9.CM code systems both for diagnosis and procedures in order to improve the standardization of data. Besides, the fitness of DRGs allocation by different codes has been judged. Some general and specific suggestions upon codes adequacy and DRGs identification have emerged from this study. The aim of this paper is to spread this preliminary standardization activity of the group as a contribution to the improvement of in-patient coded records quality.

[Differential types of pulmonary flow in bidirectional cavo-pulmonary anastomosis with an additional flow source]. / Differenti tipi di flusso polmonare nell'anastomosi cavo-polmonare bidirezionale con sorgente addizionale di flusso.

While Fontan operation is considered a palliative procedure for the treatment of complex congenital heart disease, its morbidity and mortality are certainly not negligible, especially in high-risk patients. In our opinion, a bidirectional cavo-pulmonary anastomosis with an additional source of blood flow to the lungs (Blalock-Taussig shunt, pulmonary artery banding, native pulmonary stenosis) represents a valuable surgical option in this subset of patients. From November 1992 to September 1994, sixteen patients with complex congenital heart disease underwent bidirectional cavo-pulmonary anastomosis, leaving an additional source of blood flow in place (modified Blalock-Taussig shunt in 9 cases, pulmonary artery banding in 6 cases, native pulmonary stenosis in 1 case). Eight of these patients (50%) were reinvestigated after a mean follow-up of 15.7 months (range 1-26 m). It has been possible to differentiate two types of pulmonary blood flow, according to the nature of the additional flow source; in the case of cavo-pulmonary anastomosis and pulmonary artery banding or pulmonary stenosis, pulmonary blood flow was pulsatile and evenly distributed to both lungs, while in the case of bidirectional cavo-pulmonary anastomosis and Blalock-Taussig shunt, pulmonary flow was non pulsatile and asymmetric (angiographic criteria). There were no hospital deaths. Late mortality was 12.5% (2 pts) due to worsening of atrioventricular valve regurgitation. In one of these two patients, prolonged pleural and pericardial effusion occurred. In conclusion, bidirectional cavo-pulmonary anastomosis with an additional flow source is a good alternative to classic or fenestrated Fontan operation in the treatment of complex congenital heart disease. The best results are obtained with an additional flow source represented by pulmonary artery banding or pulmonary stenosis, due to pulsatility and uniform distribution of blood flow in the pulmonary district. Morbility and mortality compare favorably with the rates observed in classic or fenestrated Fontan operation.

Bidirectional cavo-pulmonary anastomosis with an additional flow source to the lungs: clinical experience in 21 cases.

The Fontan operation is considered a palliative procedure for the treatment of complex congenital heart diseases with a morbidity and mortality that are not negligible, especially in high-risk patients. In these cases, a bidirectional cavopulmonary anastomosis with additional source of blood flow to the lungs can represent a valuable surgical option. Between November 1992 and December 1995, 21 patients with univentricular heart physiology were submitted to bidirectional cavopulmonary anastomosis with additional blood flow the additional flow consisted of an aortopulmonary shunt in 13 cases, pulmonary artery banding in seven cases, and pulmonary artery stenosis in one case. Mean age at operation was 35.5 months (range 4 months to 12 years) and mean body weight 10.9 (range 4-24.4) kg. Hospital mortality was zero. Morbidity (pleuropericardial effusions) was significant in one case. There were three late deaths (14%) caused by worsening atrioventricular valve regurgitation: two of these occurred in patients with right isomerism. Late haemodynamic evaluation documented a significant increase in cardiac output (P < 0.01) and oxygen saturation (P < 0.05) during pharmacological stress testing. Angiographic characterization of blood flow distribution to the lungs showed better results when the additional blood flow was represented by an anterograde source (pulmonary artery banding or native pulmonary artery stenosis). In conclusion, bidrectional cavopulmonary anastomosis with additional blood flow is a good alternative to classic or fenestrated Fontan technique in high-risk patients. Secondly, the diagnosis of isomerism could be a contraindication to this type of surgery, because the persistent volume overload could worsen atrioventricular valve regurgitation. Thirdly, the pharmacological stress testing shows a favourable behaviour of cardiac output and arterial oxygen saturation. Fourth, the type of additional blood flow seems to condition both pulsatility and distribution of pulmonary blood flow.

Surgical management of complete atrioventricular canal associated with tetralogy of Fallot.

Between 1984 and 1993, 12 children with an atrioventricular canal and tetralogy of Fallot underwent surgical repair. The mean(s.d.) age at operation was 58(18) months, and the mean(s.d.) body weight 15(4) kg. Nine patients underwent 11 palliative procedures. The ventricular septal defect was closed through a combined (right atrial and right ventricular) approach in nine cases, and through a right atrial approach in three, using a prosthetic patch with a wide anterior extension, secured with a running suture. The 'ostium primum' defect was closed with a separate prosthetic patch in 11 cases (double-patch technique). Right ventricular outflow obstruction was relieved by a composite infundibular patch (seven cases) or a transanular patch (five). There were four hospital deaths (33%). These were caused by low cardiac output in three cases and infection in one (three deaths occurred in patients with a transanular patch). One patient has so far died during follow-up. Assessment at 50(36) months by echo-Doppler showed moderate-to-severe 'mitral' regurgitation in three cases, and moderate 'tricuspid' regurgitation with right ventricular dysfunction in one case. Two patients have required further surgery.