A three-year old girl with right juxtaposition of the atrial appendages associated with a secundum atrial septal defect and pulmonary hypertension is reported. The appendage anomaly was demonstrated by angiography and confirmed at operation to close the atrial defect.

Child, Preschool↗

PubMedDate not supplied

Thoracic versus lumbar administration of fentanyl using patient-controlled epidural after thoracotomy.

BACKGROUND AND OBJECTIVES: Epidural fentanyl injection can provide analgesia following thoracotomy, but where to insert the catheter is a matter of debate. The study compares the effects of thoracic and lumbar patient-controlled epidural fentanyl on analgesia, fentanyl requirements, and plasma levels after thoracotomy. METHODS: Thirty patients were randomized into two groups to receive either thoracic or lumbar patient-controlled epidural fentanyl for postoperative analgesia. Postoperative pain (10 cm, visual analog scale [VAS]) and fentanyl requirements were assessed every 4 hours for 24 hours and at 12-hour intervals for the next day. Fentanyl plasma levels were measured at 8 and 16 hours after surgery. Results were expressed as mean +/- 1 SD and analyzed using Student's t-test, ANOVA, and chi-square analysis at P < .05. RESULTS: Twenty-nine patients completed the study (14 in the lumbar and 15 in the thoracic group). The VAS scores and fentanyl requirements were not significantly different at any time interval in the thoracic group as compared to the lumbar group. VAS scores at 0 hours (4.6) and 4 hours (4.6) in the lumbar group were higher than VAS scores at 12 hours (2.8; P = .04), 16 hours (2.5; P = .02), and 20 hours (2.2; P = .01) in the same group. No significant difference was found between the fentanyl plasma levels of the two groups after 8 hours (lumbar, 0.26 +/- 0.37 ng/mL; thoracic, 0.22 +/- 0.20 ng/mL) or 16 hours (lumbar, 0.36 +/- 0.17 ng/mL; thoracic, 0.44 +/- 0.32 ng/mL). CONCLUSIONS: The authors concluded that there is little if any advantage of thoracic over lumbar patient-controlled epidural fentanyl administration in patients after thoracotomy with respect to analgesia, fentanyl requirements, and plasma levels.

Analgesia, Epidural↗

PubMedDate not supplied

Executive summary.

The Canadian health system is at a crossroads. Significant health services restructuring is occurring across the country. This restructuring process provides a unique opportunity for Public Health and others to reorient the system away from illness to a focus on health--the health of individuals and communities. The purpose of this paper is to motivate and equip Public Health workers to take leadership in the restructuring, to outline key responses and strategies for Public Health associations, to raise public awareness about restructuring, and to challenge decision makers to integrate the Public Health perspective into the restructured health system. This Issue Paper describes the unique contributions Public Health has to offer health services restructuring, outlines the Public Health response to specific restructuring issues, and identifies some successful strategies for influencing change. Two key messages are explored in the paper: 1. Restructuring will be successful if it is based on an investment in health. The health of the public can be maintained and improved through changes to the institutional sector and support for health promotion, disease prevention and health protection services. 2. Public Health must be a full partner in the restructuring of health services. The Public Health perspective includes a broad understanding of the issues that are relevant to the health of individuals and communities. The skills and knowledge base offered through Public Health provide balance and equity in decision making, by ensuring full and representative involvement of community workers and the public. The uniqueness of Public Health is manifested in three distinct ways: its approach within an organized system of practice; its historical contribution; and its purposeful combination of perspectives, skills and knowledge. In partnership with communities, other health professionals and other health-determining sectors, Public Health works to protect, maintain and improve the health of Canadians. While other sectors undertake some of the functions outlined below, what makes Public Health unique is that these contributions are offered collectively through an organized system of practitioners to create a synergistic effect. Eight contributions of Public Health are identified in this paper. Specifically Public Health: Focuses on individuals and communities in a societal and global context. Builds capacity in individuals and communities to improve health. Facilitates community mobilization through community participation. Embraces promotion, prevention, protection. Influences the orientation of the health system toward health outcomes. Provides disease surveillance and control. Builds partnerships among sectors at the local level. Advocates for the health of the public. In addition to describing these contributions, the Issue Paper addresses the major trends in health services restructuring by providing an overview of the issues and outlining the Public Health response. While there is no one single model of restructuring occurring in the provinces and territories, many common themes exist. This paper highlights four categories of restructuring issues: I. Making a Difference in Health II. Skills and Knowledge Base III. Allocation of Financial Resources IV. Governance and Management.(ABSTRACT TRUNCATED AT 400 WORDS)

Canada↗