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Limitation on health care resource use is stimulating critical evaluation of previous preoperative standards. We retrospectively reviewed the clinical and hospital financial records of all children admitted for patent ductus arteriosus ligation from July 1984 to April 1994 for age, perioperative length of stay, readmissions for postoperative surgical problem, and hospital charges adjusted to 1994 dollars. Patients with an isolated patent ductus arteriosus, greater than 3 months of age, without preoperative or postoperative complications were included in this study and stratified into two groups based on date of operation. Group I had operation before January 1, 1991, and group II had operation on or after January 1, 1991. Comparison of these two groups revealed a significant difference in perioperative length of stay (group I, 3.9 +/- 1.2 days [mean +/- standard deviation]; group II, 2.7 +/- 0.9 days; p < 0.0001) and in hospital charges (group I, $8,700 +/- $2,100; group II, $6,600 +/- $1,000; p < 0.0001). These data support the premise that children older than 3 months undergoing elective ligation of a patent ductus arteriosus have been treated with improved efficiency and less charge without an increase in postdischarge morbidity. Health care policy decisions have forced us to evaluate the standards of perioperative care more critically.

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A resurgence of acute rheumatic fever (ARF) has been reported in many areas of the United States in recent years. We retrospectively reviewed the medical records of inpatients with a new diagnosis of ARF from 1982 through 1988 at a children's hospital that serves a six-state referral area in the mid-South. Thirty patients were identified, 21 of whom were seen in 1987 (13) and 1988 (8). The rate of new cases of ARF per 1000 hospital discharges (0.7) was significantly greater for 1987 and 1988 than it was (0.15) from 1982 through 1986. Patients with recently diagnosed ARF were predominantly from nonurban areas, and polyarthritis was the most common recent major manifestation. Reasons for the resurgence of ARF in the US, including the mid-South, are unclear, but our experience serves to support recently published guidelines for the diagnosis and management of streptococcal pharyngitis in light of this resurgence of ARF.

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Few data exist which address the significance of the Doppler gradient across a residual narrowing in older children who have had a coarctation repaired. Therefore, we evaluated 11 patients with repaired aortic coarctation with and without residual obstruction by Doppler echocardiography. The Doppler-derived transcoarctation pressure gradient correlated poorly with catheter-measured peak-to-peak and catheter maximal instantaneous gradients when only the maximal velocity across the repair was utilized in the simplified Bernoulli equation, [r = 0.73, standard of error of the estimate (SEE) = 5.0 mmHg and r = 0.56, SEE = 7.6 mmHg, respectively]. However, when the precoarctation velocity was included in the simplified Bernoulli equation, the correlation between Doppler-derived and catheter-measured gradients became excellent. The maximal Doppler gradient correlated well with catheter peak-to-peak gradient (r = 0.95, SEE = 2.2 mmHg) and catheter maximal instantaneous gradient (r = 0.94, SEE = 3.2 mmHg). However, the maximal Doppler gradient slightly overestimated the catheter peak-to-peak gradient and underestimated the catheter maximal instantaneous gradient. The Doppler mean gradient showed excellent correlation with the catheter mean gradient (r = 0.97, SEE = 0.85 mmHg). Precoarctation velocities were generally twofold greater than published normals due to a spatial acceleration phenomenon. All subjects had residual hypoplasia of the transverse aorta such that its transverse diameter was 29% less than, and its cross-sectional area was 50% less than, the ascending and descending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

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We undertook a study to identify the hemodynamic significance of a Doppler-derived gradient across a stenotic pulmonary valve. Furthermore, we attempted to define the optimal plane for velocity data acquisition. A total of 17 children with valvar pulmonary stenosis were evaluated using Doppler echocardiography. Flow-velocity profiles were obtained from both the parasternal and subxiphoid windows. Ten of 17 patients were studied before and after balloon valvotomy. Therefore, 27 different transvalvar gradients were assessed by Doppler and these data were compared with the catheter-derived maximal instantaneous, peak-to-peak, and mean pressure gradients. The maximal Doppler gradient correlated well with the catheter-derived peak-to-peak pressure gradient (r = 0.95) and catheter maximal instantaneous pressure gradient (r = 0.95). Although these correlation coefficients were similar, the Doppler maximal gradient consistently overestimated the peak-to-peak catheter gradient by as much as 25%-40%. Such an overestimation was not observed when we compared the maximal Doppler gradient with the catheter-derived maximal instantaneous gradient. Moreover, the regression line of the latter comparison closely approximated the line of identity. The correlation coefficient between Doppler mean and catheter mean gradients was only 0.91. Doppler velocities were best derived when multiple transducer positions were employed to interrogate pulmonary artery velocity.

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The two-dimensional echocardiographic diagnosis of multiple cardiac rhabdomyomas and evaluation of tachycardia in a fetus are presented. Prenatal echocardiographic examination defined the extent of tumor involvement and mechanism of the tachycardia and demonstrated the lack of fetal hemodynamic compromise. Perinatal, clinical and therapeutic implications are discussed.

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Cerebellar herniation with frank necrosis of the cerebellum is a rare event in infants with unfused sutures and open fontanelles. We have described this case of cerebellar herniation to emphasize its occurrence in infancy.

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Evidence from chemical and serological studies indicates that a cellular heteropolysaccharide, also found in lipid extracts and culture filtrate, is present as a group antigen in Mycobacterium tuberculosis H37Ra and in other strains of mycobacteria representing M. kansasii, scotochromogenic and Battey strains. Polysaccharides from the four strains contain the same main sugars, arabinose, and galactose, as revealed by thin-layer chromatography and spectrophotometric studies. In Ouchterlony gel diffusions, bands of identity are produced between the polysaccharides by using rabbit antiserum prepared against any of the four mycobacteria. Immune adsorption studies also confirm the presence of identical antigenic determinant groups. In skin tests with tuberculopolysaccharide I, a skin reaction of about equal size was elicited in guinea pigs sensitized with either M. tuberculosis H37Ra or heterologous mycobacterial antigens in Freund's incomplete adjuvant. In animals sensitized with M. tuberculosis H37Ra, skin tests with both homologous and heterologous polysaccharides elicited similar responses.

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The identity of a heteropolysaccharide from cell walls of Mycobacterium tuberculosis H37Ra with Seibert's tuberculopolysaccharide I was demonstrated by thin-layer chromatography, chemical analysis, and antigenic tests. The polysaccharide of M. kansasii was shown to be identical with that of M. tuberculosis. Defatted cells were disintegrated by ultrasonic treatment in the presence of glass beads; cell walls were obtained by differential ultracentrifugation. Ethyl alcohol-precipitated carbohydrate extracts were analyzed for protein and nucleic acid; these impurities were removed. Tuberculopolysaccharide I from the mycobacterial culture filtrate is probably derived from a lipopolysaccharide of the cell wall, which is partially removed by chloroform in the intact state. Alkaline extraction releases additional polysaccharide, in varying degrees of association with cell wall murein.

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