Biomedical subjects
Publications and source records attributed to A B Lewis.
One of the most distressing side effects of acne vulgaris is the development of acne scars. In this article, the authors discuss the history of and current modalities in use for the treatment of acne scars. The discussion includes resurfacing, dermabrasion, laser surgery, peels, punch excisions, and the use of fillers.
Myocarditis is defined as inflammation of the myocardium accompanied by myocellular necrosis. Acute myocarditis must be considered in patients who present with recent onset of cardiac failure or arrhythmia. Often there is a history of an antecedent flu-like illness. Fulminant myocarditis is a distinct entity characterized by sudden onset of severe congestive heart failure or cardiogenic shock, usually following a flu-like illness. Giant cell myocarditis is a rare, frequently fatal disorder of unknown origin characterized by presence of giant cell inflammatory infiltrate in the myocardium. In recent years we have made good progress in understanding the causes, pathogenesis, natural history, diagnosis, and treatment of myocarditis. However, our knowledge is still far from complete. New information that extends our understanding of myocarditis is being reported constantly. This review summarizes recent advances in myocarditis, with an emphasis on the literature during the last year.
OBJECTIVE: Angiographic visualization of systemic to pulmonary collaterals (SPC) has been documented in premature infants needing prolonged ventilatory support. Noninvasive identification of such communications in premature infants was reported recently. The purpose of this study was to describe: 1) incidence, 2) clinical findings and implications, and 3) short-term follow-up of SPC diagnosed by echocardiography in very low birth weight (VLBW) infants admitted to the neonatal intensive care unit. METHODS: From December 1, 1994 to August 31, 1996, 196 infants with birth weight <1500 g were admitted to the neonatal intensive care unit; 133 of them received serial echocardiographic evaluations at 1 to 2 days, at 2 weeks, and at 1, 2, and 3 months of life. Follow-up echocardiograms were scheduled at 6 months and 1 year of age for patients with SPC persisting at 3 months of age. RESULTS: SPC were demonstrated in 88 patients (66%) at 1 to 90 days of life (mean 28 days). In most cases, the SPC originated at the distal aortic arch or the proximal descending aorta. Ten patients (11%) were treated for congestive heart failure. The symptoms improved and anticongestive therapy was discontinued in 9. One patient with persistent congestive heart failure underwent therapeutic cardiac catheterization and 1 prominent SPC was embolized. CONCLUSIONS: The incidence of SPC in VLBW infants is much higher than previously reported. We postulate that SPC are bronchopulmonary communications that enlarge and/or proliferate in response to a given stimulus. These communications are associated with increased time on positive pressure ventilation and length of stay in the hospital. SPC may lead to pulmonary edema and should be searched for in VLBW infants with a more complicated course. Echocardiographic examination with color Doppler performed in premature infants to evaluate left to right shunts should include careful search for systemic to pulmonary collaterals.echocardiography, systemic to pulmonary collaterals, aortopulmonary collaterals, prematurity, pulmonary edema.
BACKGROUND: The prognosis for children with idiopathic dilated cardiomyopathy (IDC) is variable. Patients who fail to exhibit improvement in left ventricular (LV) function have a high 1-year mortality rate, whereas improvement in LV fractional shortening (LVFS) to >15% is associated with better survival. However, complete recovery of LV performance to normal has not been examined. METHODS AND RESULTS: The clinical features and echocardiograms of 63 children with IDC were reviewed. Sixteen patients (group 1) were identified who demonstrated progressive improvement in LVFS, ultimately recovering to within the normal range. They were compared with 47 patients (group 2) in whom LVFS remained depressed. Group 1 LVFS at first examination was 13.6% +/- 5.1%, z = -10.8 +/- 4.0, and improved to within the normal range (33.7% +/- 3.4%, z = -0.9 +/- 1. 4, P <.001). Group 2 initial LVFS was 13.6 +/- 2.3, z = -8.9 +/- 3.2 and did not change significantly (15.7% +/- 7.3%, z = -7.3 +/- 1.6). The LV was dilated at initial examination in all patients (z = 6.9 +/- 3.0). Recovery in group 1 was associated with a decrease in LV dimension to within the normal range (z = 1.3 +/- 1.6, P <.001), whereas the LV dimension in group 2 patients remained increased (z = 6.2 +/- 3.4). The mean follow-up time at which LV function was noted to be normal was 4.5 +/- 3.6 years (range 0.3 to 14 years). The total duration of follow-up was 6.5 +/- 5.2 years (range 1 to 16 years). CONCLUSIONS: Complete recovery of LV function is possible in children with IDC. Recovery may occur within the first year after initial examination in some patients, but longer periods are needed in the majority of patients in whom LV function ultimately returned to normal.
BACKGROUND: Over the past decade, the 585-nm pulsed dye laser (PDL) has been used successfully to treat a variety of cutaneous vascular lesions as well as hypertrophic scars. Laser scar revision has been revolutionized by the recent development of high-energy, pulsed carbon dioxide (CO2) laser systems. These new CO2 lasers allow controlled vaporization of thin layers of skin while minimizing damage to surrounding dermal structures. OBJECTIVE: To determine the effect of a high-energy, pulsed CO2 laser alone and in combination with a 585-nm PDL on nonerythematous hypertrophic scars. METHODS: Twenty patients with nonerythematous hypertrophic scars were treated with a high-energy, pulsed CO2 laser. One-half of each scar was additionally treated with the 585-nm PDL laser. Sequential clinical and photographic analyses were performed independently by two blinded assessors. In addition, erythema reflectance spectrometry measurements were obtained from the scars before and at regular postoperative intervals. RESULTS: Global assessment scores and erythema spectrometry measurements were significantly improved after laser treatment. Combination CO2 and PDL laser treatment resulted in more significant improvement than CO2 laser irradiation alone. CONCLUSION: Concomitant use of the high-energy, pulsed CO2 and PDL laser systems was superior to CO2 laser vaporization alone for revision of nonerythematous hypertrophic scars. Once again, the vascular specificity of the 585-nm PDL has been linked to improvement in hypertrophic scar tissue.
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Evaluation of the aging face reveals many changes such as lentigines, coarseness, senile purpura, and fine lines that can be blamed primarily on photoaging. There are many topical preparations that are now being used or are under investigation for facial rejuvenation. These include retinold creams, alpha-hydroxy acids, Ethocyn (Chantal Skin Care Corp, Los Angeles, CA), topical vitamins, and topical hormonal treatments. There has been substantial media attention devoted to these "antiaging" cures but there is a lack of scientific evidence to support some of these claims. After review of these agents, a practical approach to the patient requesting younger-looking skin is presented.
BACKGROUND: The optimal surgical treatment of complex (multiple level or recurrent) left ventricular outflow tract obstruction (LVOTO) in infancy is controversial. Staged procedures expose the children to the need for reoperation, and currently available techniques of aortoventriculoplasty are associated with the morbidities of biological and mechanical prostheses. METHODS: Between July 1992 and January 1996, we have performed 24 aortic root replacements with the pulmonary autograft in pediatric patients (< 18 years). Of this group, 8 were infants and children with complex LVOTO aged 9 days to 22 months (mean, 8.6 +/- 8 months) and weighing 3.3 to 10.2 kg (mean, 6.3 +/- 2.6 kg). The diagnoses were interrupted aortic arch/ventricular septal defect/subaortic stenosis in 3, recurrent aortic stenosis in 2, aortic stenosis and subaortic stenosis in 1, and aortic stenosis/subaortic stenosis/mitral stenosis/regurgitation in 2. All patients had undergone one to three previous operative procedures (mean, 1.5 +/- 0.8 procedures/patient). Preoperative echocardiographic peak LVOT gradient was 71.7 +/- 25 mm Hg (range, 40 to 110 mm Hg) and aortic annulus size was 7.2 +/- 2.3 mm (range, 4 to 10.6 mm). The surgical technique included replacement of the aortic root with the pulmonary autograft combined with incision of the conal septum to relieve subaortic stenosis or accommodate for size discrepancy between the aortic and pulmonary autograft root and a pulmonary homograft placed in the right ventricular outflow tract. RESULTS: There were no perioperative or late deaths at follow-up (range, 2 to 25 months; mean, 13.5 +/- 8 months). Mean hospital stay was 15 +/- 17 days (range, 4 to 53 days). Three children had the following complications: diaphragmatic paresis (1), delayed pericardial effusion (1), and atrioventricular block requiring a pacemaker (1). In follow-up, echocardiographic findings showed absent aortic regurgitation in 3 and trivial aortic regurgitation in 5, and no significant LVOTO (mean peak gradient, 6.2 +/- 7.6 mm Hg; range, 0 to 16 mm Hg). Pulmonary homograft regurgitation was absent in 5, trivial in 2, and moderate in 1. Peak right ventricular outflow tract gradient by echocardiogram was trivial in 7, and a significant gradient of 55 mm Hg has developed in 1 infant. There were no infective or embolic complications during follow-up. CONCLUSIONS: Our experience shows that aortic root replacement with the pulmonary autograft can be performed in children with excellent clinical results. The technique of root replacement combined with ventriculoplasty allows definitive and simultaneous relief of complex and multiple-level obstructive lesions. Considering the growth potential of the pulmonary autograft, this should be regarded as the optimal treatment modality in infants with complex LVOTO:
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Mortality of pediatric patients with idiopathic dilated cardiomyopathy (IDC) is highest during the first 1 to 2 years the child is first seen. The echocardiograms of 72 infants and children with IDC were reviewed to determine whether left ventricular shortening fraction (LVSF), end-diastolic dimension, and wall mass were helpful in predicting outcome. Patients who were alive at last follow-up (group 1) were compared to those who died or required heart transplant (group 2). None of the indexes obtained at first examination were predictive of survival. Shortening fraction had improved significantly at follow-up 1 to 6 months after first examination in group 1 (15.1 +/- 0.9 to 24.4 +/- 1.8, p < 0.001) but remained unchanged in group 2 (14.1 +/- 1.5 to 15.3 +/- 3.2). No significant trends were noted in left ventricular end-diastolic dimension or wall mass. The 1- and 5-year actuarial survival for all patients was 75% and 60%, respectively. Persistent depression of LVSF < 15% was associated with a significantly lower survival rate (1-year 46%; 5-year 29%) compared to patients in whom follow-up LVSF was > 15% (1-year 97%; 5-year 90%; p < 0.05). It is concluded that the follow-up LVSF obtained at least 1 month after first examination is helpful in identifying pediatric patients who would benefit from early cardiac transplantation.
BACKGROUND: Myocardial damage in myocarditis is mediated, in part, by immunological mechanisms. High-dose intravenous gamma-globulin (IVIG) is an immunomodulatory agent that is beneficial in myocarditis secondary to Kawasaki disease, as well as in murine myocarditis. Since 1990, the routine management of presumed acute myocarditis at Children's Hospital, Boston, and Children's Hospital, Los Angeles, has included administration of high-dose IVIG. METHODS AND RESULTS: We treated 21 consecutive children presenting with presumed acute myocarditis with IVIG, 2 g/kg, over 24 hours, in addition to anticongestive therapies. A comparison group comprised 25 recent historical control patients meeting identical eligibility criteria but not receiving IVIG therapy. Left ventricular function was assessed during five time intervals: 0 to 7 days, 1 to 3 weeks, 3 weeks to 3 months, 3 to 6 months, and 6 to 12 months. At presentation, the IVIG and non-IVIG groups had comparable left ventricular enlargement and poor fractional shortening. Compared with the non-IVIG group, those treated with IVIG had a smaller mean adjusted left ventricular end-diastolic dimension and higher fractional shortening in the periods from 3 to 6 months (P = .008 and P = .033, respectively) and 6 to 12 months (P = .072 and P = .029, respectively). When adjusting for age, biopsy status, intravenous inotropic agents, and angiotensin-converting enzyme inhibitors, patients treated with IVIG were more likely to achieve normal left ventricular function during the first year after presentation (P = .03). By 1 year after presentation, the probability of survival tended to be higher among IVIG-treated patients (.84 versus .60, P = .069). We observed no adverse effects of IVIG administration. CONCLUSIONS: These data suggest that use of high-dose IVIG for treatment of acute myocarditis is associated with improved recovery of left ventricular function and with a tendency to better survival during the first year after presentation.
Outcome in 81 pediatric patients with dilated cardiomyopathy was reviewed to assess whether treatment with angiotensin-converting enzyme (ACE) inhibitors affected survival. Age at onset was 3.6 +/- 0.6 years. Twenty-seven children (group 1) were treated with ACE inhibitors. Conventional therapy was used in the remaining 54 patients (group 2). There were no significant differences between the two groups in age at onset, left ventricular shortening fraction, left ventricular end-diastolic pressure, or mean pulmonary artery pressure. Patients treated with ACE inhibitors had a significantly better survival during the first year (p < 0.05) with continuation of this trend throughout the second year (p = 0.06). Beyond 2 years there was a tendency toward better survival in ACE inhibitor-treated patients, but the differences were no longer significant (p = 0.14). These data, along with observations in adult patients with chronic cardiac failure, indicate that converting enzyme inhibitors have a beneficial effect on prolonging survival of infants and children with severe left ventricular dysfunction from dilated cardiomyopathy.
The evaluation of left ventricular systolic performance in infants undergoing extracorporeal membrane oxygenation (ECMO) using traditional ejection-phase indices is hampered by significant alterations in preload and afterload. Therefore, a load-independent index, which relates heart-rate-corrected mean velocity of circumferential fiber shortening (VCFc) to afterload, measured as end-systolic wall stress (ESS), was used to assess left ventricular function in 18 term neonates undergoing ECMO. The mean age at the onset of ECMO was 75.5 h and the duration of therapy was 171 +/- 106 h. Left ventricular performance was highest before the onset of ECMO (VCFc = 1.65 +/- 0.49 circ/s) and decreased toward normal during (1.38 +/- 0.33 circ/s) and following ECMO (1.29 +/- 0.16 circ/s). Initially, nine of 17 (53%) patients had enhanced performance for the degree of afterload but in only 16 of 48 (33%) studies during ECMO and none following ECMO was VCFc elevated beyond the normal range predicted for ESS. These changes in left ventricular performance may be the result of variations in exogenous, as well as endogenous, catecholamines rather than intrinsic alterations in myocardial contractility. It is concluded that the VCFc/ESS relation permits a meaningful assessment of ventricular performance in critically ill neonates undergoing ECMO.
The clinical profile and outcome of idiopathic restrictive cardiomyopathy in a group of eight children are reviewed. There were six girls and two boys. Age at presentation was 4.0 +/- 2.6 years (range 1.3 to 9.5 years). All patients had evidence of congestive heart failure with systemic venous congestion. Right or left atrial enlargement was the most consistent ECG finding and was present in all patients. Left ventricular shortening fraction was normal in five patients, increased in two, and mildly reduced in one. The most striking echocardiographic feature was severe biatrial dilatation in the presence of normal or near-normal ventricular cavity dimensions. Marked elevation of left ventricular end-diastolic pressure was noted in all seven patients undergoing cardiac catheterization (34 +/- 7 torr; range 24 to 40 torr). Right ventricular end-diastolic pressure was elevated but significantly different from left ventricular pressure (18 +/- 7 torr; p less than 0.01). A characteristic early diastolic dip with a rapid rise to an elevated plateau (square root sign) was present in five of seven patients. Median survival was 1.4 years. Six patients died 0.2 to 7.0 years after they were initially seen. The actuarial survival rate 1.5 years after presentation was 44%, decreasing to 29% at 4 years. Restrictive cardiomyopathy has a worse prognosis in children than in adults. In part this may reflect the more advanced symptoms of congestive failure at initial presentation. Pediatric patients should be considered for early cardiac transplantation.
A review of 81 infants and children with dilated, poorly contracting left ventricles without associated structural abnormalities was undertaken to identify risk factors for poor outcome, which could be used in selecting candidates for cardiac transplantation. Significant atrial or ventricular dysrhythmias, or both, were detected on presentation or during follow-up in 24 patients. Arrhythmias were present in only 8 of 51 survivors (16%) but were detected in 16 of 30 patients (53%) who died (p less than 0.05). Patients dying suddenly were even more likely to have had documented dysrhythmias (8 of 11, p less than 0.05). Left ventricular shortening fraction was similar in survivors and nonsurvivors (14.9 +/- 1.0% vs 15.3 +/- 1.7%). Left ventricular end-diastolic pressure in 44 patients who had cardiac catheterization averaged 20.8 +/- 1.6 mm Hg. Left ventricular end-diastolic pressure was significantly higher in patients who died than in those who survived (29.5 +/- 2.2 vs 15.0 +/- 1.6 mm Hg, p less than 0.001). Analysis of actuarial survival revealed that mortality was highest during the first 6 months after presentation (19% mortality). Survival declined more gradually thereafter and was 70% at 2 years, 64% at 5 years and 52% after 11.5 years. Age at initial presentation did not have any significant impact on survival. However, left ventricular end-diastolic pressure greater than 25 torr was associated with a significantly increased mortality rate (p less than 0.05). Early cardiac transplantation should be considered in patients with markedly elevated left ventricular end-diastolic pressure or complex atrial or ventricular arrhythmias.
Data from 694 untreated children seen in a private orthodontic practice were used to analyze associations between dental and skeletal maturity. Dental ages were obtained by comparison with Bolton Standards; skeletal ages were assessed using the Greulich-Pyle atlas. In some children the difference between the dental and skeletal ages was as large as 36 months; the difference was less than 6 months in fewer than 40% of the children. Regression analyses showed only moderate associations between these measures. One measure of maturity cannot be inferred from the other.
The interaction between the plasma catecholamine response to hypoxemia and endogenous opiate receptor blockade was investigated in 9 fetal lambs. The animals were randomly assigned to receive either normal saline (control group 1) or two doses of naloxone (group 2 = 0.5 mg/kg; group 3 = 1.0 mg/kg) by bolus injection followed by continuous infusion. Arterial PO2 decreased from 21 to 12 Torr and remained less than 14 Torr for 1 h. Arterial pH declined from 7.40 to a nadir of 7.32 at 1 h. Mean plasma catecholamine concentrations rose promptly from a baseline of 524-546 pg/ml for norepinephrine (NE) and 156-235 pg/ml for epinephrine (E) to reach a peak at 15 min (NE = 2,476-3,276, p less than 0.01; E = 1,856-4,065 pg/ml, p less than 0.01) and remained elevated thereafter. Neither dose of naloxone significantly altered plasma NE or E concentrations. Therefore, we conclude that endogenous opiates do not modulate the sympathoadrenal response to moderately long periods of hypoxemia unaccompanied by acidemia.
This paper reports the results at follow-up of a randomized clinical trial of combining family intervention with drug treatment during hospitalization for patients with affective disorder. The results suggest that female bipolar patients and their families benefited from family intervention, whereas unipolar patients and families did not. Patient outcome was positively correlated with the achievement of the goals of family intervention.