J. Peter Harris

Early closure of the patent ductus arteriosus in very low-birth-weight infants: A controlled trial

A controlled clinical trial comparing early closure (mean = 48.8 hours) of the patent ductus arteriosus using indomethacin to conventional medical management, with intervention only after cardiopulmonary decompensation (mean = 167.4 hours), was undertaken in 24 preterm infants with severe respiratory distress syndrome and evidence of PDA. An interval analysis of one-half the projected sample revealed that infants undergoing early closure of the PDA had significantly reduced occurrence of BPD or mortality by 6 months of age. A comparison of birth weight, Apgar scores, gestational age, age of initial PDA diagnosis, and fluid therapy during the first seven days of life showed no significant differences between early intervention and control groups. At the time of the interval analysis, there were no differences between the groups in duration of intermittent mandatory ventilation or oxygen exposure. Studies will be required to determine whether these and other variables can be altered by early closure of the PDA.

Dissecting Aortic Aneurysm in Childhood and Adolescence Case Report and Literature Review

A 15-year-old adolescent male with dissecting aortic aneurysm is presented. His young age, lack of predisposing factors, and fulminant course with rapid progression to death precluded a correct antemortem diagnosis. Review of the literature reveals that most instances of dissecting aortic aneurysm in childhood and adolescence are associated with predisposing conditions, es pecially congenital cardiovascular anomalies. The clinical picture is generally characteristic. Prompt evaluation and therapy may be lifesaving.

Discordance Between Resident and Faculty Perceptions of Resident Autonomy: Can Self-determination Theory Help Interpret Differences and Guide Strategies for Bridging the Divide?

Purpose To identify and interpret differences between resident and faculty perceptions of resident autonomy and of faculty support of resident autonomy. Method Parallel questionnaires were sent to pediatric residents and faculty at the University of Rochester Medical Center in 2011. Items addressed self-determination theory (SDT) constructs (autonomy, competence, relatedness) and asked residents and faculty to rate and/or comment on their own and the other group’s behaviors. Distributions of responses to 17 parallel Likert scale items were compared by Wilcoxon rank-sum tests. Written comments underwent qualitative content analysis. Results Respondents included 62/78 residents (79%) and 71/100 faculty (71%). The groups differed significantly on 15 of 17 parallel items but agreed that faculty sometimes provided too much direction. Written comments suggested that SDT constructs were closely interrelated in residency training. Residents expressed frustration that their care plans were changed without explanation. Faculty reported reluctance to give “passive” residents autonomy in patient care unless stakes were low. Many reported granting more independence to residents who displayed motivation and competence. Some described working to overcome residents’ passivity by clarifying and reinforcing expectations. Conclusions Faculty and residents had discordant perceptions of resident autonomy and of faculty support for resident autonomy. When faculty restrict the independence of “passive” residents whose competence they question, residents may receive fewer opportunities for active learning. Strategies that support autonomy, such as scaffolding, may help residents gain confidence and competence, enhance residents’ relatedness to team members and supervisors, and help programs adapt to accreditation requirements to foster residents’ growth in independence.

Two-dimensional echocardiographic identification of pulmonary artery branch stenosis.

Pulmonary artery branch stenosis is a not uncommon congenital lesion, noted in approximately 4% of children at the time of cardiac catheterization. Real-time 2-dimensional echocardiography was used to examine 10 patients with angiographically documented pulmonary branch stenosis. Five cases of pulmonary artery branch narrowing were identified by echocardiography without prior knowledge of angiographic findings. In 5 other patients whose angiographic results were known, the narrowings were identified in 4 of 5 cases. These results demonstrate the feasibility of evaluating pulmonary branch stenosis with the nonionizing, noninvasive method of 2-dimensional echocardiography.

Coronary Artery Injury by a Valved External Conduit

A 4-month-old infant underwent repair of type I truncus arteriosus and died immediately after as a consequence of left main coronary artery compression by the metallic stent in the Dacron conduit. To avoid injury to the coronary vasculature, the future location of the porcine valve ring should be assessed and relocated if necessary.

DEATH IN ADOLESCENTS WITH CARDIOVASCULAR DISEASE: A COMPARISON OF SEQUENTIAL 10-YEAR COHORTS. |[dagger]| 14

Although cardiovascular disease ranks as the 6th leading cause of mortality in adolescents, the etiology and epidemiology of death has not been evaluated systematically. We studied 100 patients with known congenital or acquired heart disease from a university hospital pediatric cardiology service who died between 11 and 21 years of age during the intervals 1974 to 1984 and 1984 to 1994. Sudden death was defined as unexpected, unpredictable, instantaneous death in non-hospitalized patients of presumed cardiac cause. When the activity level at the time of death was known, < 10% of patients were engaged in moderate or strenuous exercise. Table