David Wypij

Developmental and Neurologic Status of Children after Heart Surgery with Hypothermic Circulatory Arrest or Low-Flow Cardiopulmonary Bypass

Background Deep hypothermia with either total circulatory arrest or low-flow cardiopulmonary bypass is used to support vital organs during heart surgery in infants. We compared the developmental and neurologic sequelae of these two strategies one year after surgery. Methods Infants with D-transposition of the great arteries who underwent an arterial-switch operation were randomly assigned to a method of support consisting predominantly of circulatory arrest or a method consisting predominantly of low-flow bypass. Developmental and neurologic evaluations and magnetic resonance imaging (MRI) were performed at one year of age. Results Of the 171 patients enrolled in the study, 155 were evaluated. After adjustment for the presence or absence of a ventricular septal defect, the infants assigned to circulatory arrest, as compared with those assigned to low-flow bypass, had a lower mean score on the Psychomotor Development Index of the Bayley Scales of Infant Development (a 6.5-point deficit, P = 0.01) and a hig...

Postoperative Course and Hemodynamic Profile After the Arterial Switch Operation in Neonates and Infants A Comparison of Low-Flow Cardiopulmonary Bypass and Circulatory Arrest

BACKGROUND The neurological morbidity associated with prolonged periods of circulatory arrest has led some cardiac surgical teams to promote continuous low-flow cardiopulmonary bypass as an alternative strategy. The nonneurological postoperative effects of both techniques have been previously studied only in a limited fashion. METHODS AND RESULTS We compared the hemodynamic profile (cardiac index and systemic and pulmonary vascular resistances), intraoperative and postoperative fluid balance, and perioperative course after deep hypothermia and support consisting predominantly of total circulatory arrest or low-flow cardiopulmonary bypass in a randomized, single-center trial. Eligibility criteria included a diagnosis of transposition of the great arteries and a planned arterial switch operation before the age of 3 months. Of the 171 patients, 129 (66 assigned to circulatory arrest and 63 to low-flow bypass) had an intact ventricular septum and 42 (21 assigned to circulatory arrest and 21 to low-flow bypass) had an associated ventricular septal defect. There were 3 (1.8%) hospital deaths. Patients assigned to low-flow bypass had significantly greater weight gain and positive fluid balance compared with patients assigned to circulatory arrest. Despite the increased weight gain in the infants assigned to low-flow bypass, the duration of mechanical ventilation, stay in the intensive care unit, and hospital stay were similar in both groups. Hemodynamic measurements were made in 122 patients. During the first postoperative night, the cardiac index decreased (32.1 +/- 15.4%, mean +/- SD), while pulmonary and systemic vascular resistance increased. The measured cardiac index was < 2.0 L.min-1.m-2 in 23.8% of the patients, with the lowest measurement typically occurring 9 to 12 hours after surgery. Perfusion strategy assignment was not associated with postoperative hemodynamics or other nonneurological postoperative events. CONCLUSIONS After heart surgery in neonates and infants, both low-flow bypass and circulatory arrest perfusion strategies have comparable effects on the nonneurological postoperative course and hemodynamic profile.

A comparison of the perioperative neurologic effects of hypothermic circulatory arrest versus low-flow cardiopulmonary bypass in infant heart surgery

Background Hypothermic circulatory arrest is a widely used support technique during heart surgery in infants, but its effects on neurologic outcome have been controversial. An alternative method, low-flow cardiopulmonary bypass, maintains continuous cerebral circulation but may increase exposure to known pump-related sources of brain injury, such as embolism or inadequate cerebral perfusion. Methods We compared the incidence of perioperative brain injury after deep hypothermia and support consisting predominantly of total circulatory arrest with the incidence after deep hypothermia and support consisting predominantly of low-flow cardiopulmonary bypass in a randomized, single-center trial. The criteria for eligibility included a diagnosis of transposition of the great arteries with an intact ventricular septum or a ventricular septal defect and a planned arterial-switch operation before the age of three months. Results Of 171 patients with D-transposition of the great arteries, 129 (66 of whom were assign...

Effects of Cigarette Smoking on Lung Function in Adolescent Boys and Girls

BACKGROUND Little is known about the sex-specific effects of cigarette smoking on the level and growth of lung function in adolescence, when 71 percent of people in the United States who smoke tried their first cigarette. METHODS We studied the effects of cigarette smoking on the level and rate of growth of pulmonary function in a cohort of 5158 boys and 4902 girls 10 to 18 years of age, examined annually between 1974 and 1989 in six cities in the United States. RESULTS We found a dose-response relation between smoking and lower levels of both the ratio of forced expiratory volume in one second to forced vital capacity (FEB1/FVC) and the forced expiratory flow between 25 and 75 percent of FVC (FEF25-75). Each pack per day of smoking was associated with a 3.2 percent reduction in FEF25-75 for girls (P=0.01) and a 3.5 percent reduction in FEF25-75 for boys (P=0.007). Whereas the FVC level was elevated in smokers, the rate of growth of FVC and FEV1 was reduced. Among adolescents of the same sex, smoking five or more cigarettes a day, as compared with never smoking, was associated with 1.09 percent slower growth of FEV1 per year in girls (95 percent confidence interval 0.70 to 1.47) and 0.20 percent slower growth in boys (95 percent confidence interval, -0.16 to 0.56), and with 1.25 percent slower growth of FEF25-75 per year in girls (95 percent confidence interval 0.38 to 2.13) and 0.93 percent slower growth in boys (95 percent confidence interval, 0.21 to 1.65). Whereas girls who did not smoke reached a plateau of lung function at 17 to 18 years of age, girls of the same age who smoked had a decline of FEV1 and FEF25-75. CONCLUSION Cigarette smoking is associated with evidence of mild airway obstruction and slowed growth of lung function in adolescents. Adolescent girls may be more vulnerable than boys to the effects of smoking on the growth of lung function.

Dimensions of women’s autonomy and the influence on maternal health care utilization in a north indian city

The dimensions of women’s autonomy and their relationship to maternal health care utilization were investigated in a probability sample of 300 women in Varanasi, India. We examined the determinants of women’s autonomy in three areas: control over finances, decision-making power, and freedom of movement. After we control for age, education, household structure, and other factors, women with closer ties to natal kin were more likely to have greater autonomy in each of these three areas. Further analyses demonstrated that women with greater freedom of movement obtained higher levels of antenatal care and were more likely to use safe delivery care. The influence of women’s autonomy on the use of health care appears to be as important as other known determinants such as education.

Neurodevelopmental status at eight years in children with dextro-transposition of the great arteries: The Boston Circulatory Arrest Trial

OBJECTIVES Our goal was to determine which of the two major methods of vital organ support used in infant cardiac surgery, total circulatory arrest and low-flow cardiopulmonary bypass, results in better neurodevelopmental outcomes at school age. METHODS In a single-center trial, infants with dextrotransposition of the great arteries underwent the arterial switch operation after random assignment to either total circulatory arrest or low-flow cardiopulmonary bypass. Developmental, neurologic, and speech outcomes were assessed at 8 years of age in 155 of 160 eligible children (97%). RESULTS Treatment groups did not differ in terms of most outcomes, including neurologic status, Full-Scale or Performance IQ score, academic achievement, memory, problem solving, and visual-motor integration. Children assigned to total circulatory arrest performed worse on tests of motor function including manual dexterity with the nondominant hand (P =.003), apraxia of speech (P =.01), visual-motor tracking (P =.01), and phonologic awareness (P =.003). Assignment to low-flow cardiopulmonary bypass was associated with a more impulsive response style on a continuous performance test of vigilance (P <.01) and worse behavior as rated by teachers (P =.05). Although mean scores on most outcomes were within normal limits, neurodevelopmental status in the cohort as a whole was below expectation in many respects, including academic achievement, fine motor function, visual-spatial skills, working memory, hypothesis generating and testing, sustained attention, and higher-order language skills. CONCLUSIONS Use of total circulatory arrest to support vital organs during heart surgery in infancy is generally associated with greater functional deficits than is use of low-flow cardiopulmonary bypass, although both strategies are associated with increased risk of neurodevelopmental vulnerabilities.

Developmental and Neurological Status of Children at 4 Years of Age After Heart Surgery With Hypothermic Circulatory Arrest or Low-Flow Cardiopulmonary Bypass

BACKGROUND It is not known whether developmental and neurological outcomes in the preschool period differ depending on whether the predominant vital organ support strategy used in infant heart surgery was total circulatory arrest (CA) or low-flow cardiopulmonary bypass. METHODS AND RESULTS Infants with D-transposition of the great arteries who underwent an arterial-switch operation were randomly assigned to a support method consisting predominantly of CA or low-flow cardiopulmonary bypass. Developmental and neurological status were evaluated blindly at 4 years of age in 158 of 163 eligible children (97%). Neither IQ scores nor overall neurological status were significantly associated with either treatment group or duration of CA. The CA group scored lower on tests of motor function (gross motor, P=0.01; fine motor, P=0.03) and had more severe speech abnormalities (oromotor apraxia, P=0.007). Seizures in the perioperative period, detected either clinically or by continuous electroencephalographic monitoring, were associated with lower mean IQ scores (12.6 and 7.7 points, respectively) and increased risk of neurological abnormalities (odds ratios, 8.4 and 5.6, respectively). The performance of the full cohort was below expectations in several domains, including IQ, expressive language, visual-motor integration, motor function, and oromotor control. CONCLUSIONS Use of CA to support vital organs during open heart surgery in infancy is associated, at the age of 4 years, with worse motor coordination and planning but not with lower IQ or with worse overall neurological status.

Perioperative effects of alpha-stat versus pH-stat strategies for deep hypothermic cardiopulmonary bypass in infants.

OBJECTIVES In a randomized, single-center trial, we compared perioperative outcomes in infants undergoing cardiac operations after use of the alpha-stat versus pH-stat strategy during deep hypothermic cardiopulmonary bypass. METHODS Admission criteria included reparative cardiac surgery, age less than 9 months, birth weight 2.25 kg or more, and absence of associated congenital or acquired extracardiac disorders. RESULTS Among the 182 infants in the study, diagnoses included D-transposition of the great arteries (n = 92), tetralogy of Fallot (n = 50), tetralogy of Fallot with pulmonary atresia (n = 6), ventricular septal defect (n = 20), truncus arteriosus (n = 8), complete atrioventricular canal (n = 4), and total anomalous pulmonary venous return (n = 2). Ninety patients were assigned to alpha-stat and 92 to pH-stat strategy. Early death occurred in four infants (2%), all in the alpha-stat group (p = 0.058). Postoperative electroencephalographic seizures occurred in five of 57 patients (9%) assigned to alpha-stat and one of 59 patients (2%) assigned to pH-stat strategy (p = 0.11). Clinical seizures occurred in four infants in the alpha-stat group (4%) and two infants in the pH-stat group (2%) (p = 0.44). First electroencephalographic activity returned sooner among infants randomized to pH-stat strategy (p = 0.03). Within the homogeneous D-transposition subgroup, those assigned to pH-stat tended to have a higher cardiac index despite a lower requirement for inotropic agents; less frequent postoperative acidosis (p = 0.02) and hypotension (p = 0.05); and shorter duration of mechanical ventilation (p = 0.01) and intensive care unit stay (p = 0.01). CONCLUSIONS Use of the pH-stat strategy in infants undergoing deep hypothermic cardiopulmonary bypass was associated with lower postoperative morbidity, shorter recovery time to first electroencephalographic activity, and, in patients with D-transposition, shorter duration of intubation and intensive care unit stay. These data challenge the notion that alpha-stat management is a superior strategy for organ protection during reparative operations in infants using deep hypothermic cardiopulmonary bypass.

Adolescents With d-Transposition of the Great Arteries Corrected With the Arterial Switch Procedure Neuropsychological Assessment and Structural Brain Imaging

Background— We report neuropsychological and structural brain imaging assessments in children 16 years of age with d-transposition of the great arteries who underwent the arterial switch operation as infants. Children were randomly assigned to a vital organ support method, deep hypothermia with either total circulatory arrest or continuous low-flow cardiopulmonary bypass. Methods and Results— Of 159 eligible adolescents, 139 (87%) participated. Academic achievement, memory, executive functions, visual-spatial skills, attention, and social cognition were assessed. Few significant treatment group differences were found. The occurrence of seizures in the postoperative period was the medical variable most consistently related to worse outcomes. The scores of both treatment groups tended to be lower than those of the test normative populations, with substantial proportions scoring ≥1 SDs below the expected mean. Although the test scores of most adolescents in this trial cohort are in the average range, a substantial proportion have received remedial academic or behavioral services (65%). Magnetic resonance imaging abnormalities were more frequent in the d-transposition of the great arteries group (33%) than in a referent group (4%). Conclusions— Adolescents with d-transposition of the great arteries who have undergone the arterial switch operation are at increased neurodevelopmental risk. These data suggest that children with congenital heart disease may benefit from ongoing surveillance to identify emerging difficulties. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000470.

The prevalence of homosexual behavior and attraction in the United States, the United Kingdom and France: Results of national population-based samples

Researchers determining the prevalence of homosexuality in nationally representative samples have focused upon determining the prevalence of homosexual behavior, ignoring those individuals whose sexual attraction to the same sex had not resulted in sexual behavior. We examine the use of sexual attraction as well as sexual behavior to estimate the prevalence of homosexuality in the United States, the United Kingdom, and France using the Project HOPE International Survey of AIDS-Risk Behaviors. We find that 8.7, 7.9, and 8.5% of males and 11.1, 8.6, and 11.7% of females in the United States, the United Kingdom, and France, respectively, report some homosexual attraction but no homosexual behavior since age 15. Further, considering homosexual behavior and homosexual attraction as different but overlapping dimensions of homosexuality, we find 20.8, 16.3, and 18.5% of males, and 17.8, 18.6, and 18.5% of females in the United States, the United Kingdom, and France report either homosexual behavior or homosexual attraction since age 15. Examination of homosexual behavior separately finds that 6.2, 4.5, and 10.7% of males and 3.6, 2.1, and 3.3% of females in the United States, the United Kingdom, and France, respectively, report having had sexual contact with someone of the same sex in the previous 5 years. Our findings highlight the importance of using more than just homosexual behavior to examine the prevalence of homosexuality.