National belonging and psychological strain among Finnish migrant populations

Background

National identities are socially constructed and imaginary groups with real-life consequences. Migrants are in a heightened risk to be treated as ‘others’ who do not belong to society. It remains unclear, to what extent national belonging is experienced among Finnish migrants and what consequences on health this has. We study migrants’ sense of belonging to Finns, how it’s manifested in sociodemographic groups and whether it’s associated with psychological strain.

Methods

We used nationally representative data from the cross-sectional Survey on Well-Being among Foreign-Born Population (FinMonik, n = 6836). National belonging was assessed by the item “Finns” in question “which of the following areas or groups you feel you belong to?”. Response options fully and quite a lot were coded to indicate sense of belonging. Logistic regression was used to test the association between belonging, sociodemographic factors and psychological strain (MHI-5). Weights were used to correct the sample.

Results

51% reported sense of belonging to Finns. 46% of those aged 30-44 reported sense of belonging to Finns, whereas the youngest and oldest age groups yielded highest prevalences (18-29=53% and 45-64=58%, p<.001). Married persons reported sense of belonging to Finns more than those who weren't (55% vs. 48%, p<.01). Country group accounted for the variation in Finnish identification with a p-value of less than 0.001. Only 27 percent of those born in East Asia reported sense of belonging to Finns, whereas almost 60% of those born in Middle East and North Africa sensed belonging to Finns. Those with sense of belonging to Finns were twice as likely to report lack of psychological strain than those with no sense of belonging to Finns (p<.001).

Conclusions

Achieving national belonging to the receiving society seems to be more difficult or non-appealing for some migrant populations than others. Lack of national belonging poses risk of deterioration of mental health.

Key messages

• The socially constructed boundaries of national belonging can be exclusionary and have negative consequences for the health of migrant populations.

• Experiencing a sense of national belonging to the country of residence has positive associations with mental wellbeing.

Better mental health through identifying with locals and country of origin among foreign-born people

Background

Sense of belonging (SoB) is an important determinant of health among foreign-born population and it has previously been found to be associated with perceived health. In this study we examined: 1) which types of SoB are associated with psychological strain (PS), and 2) whether this varies between different country groups.

Methods

The data were gathered from the cross-sectional Survey on Well-Being among Foreign-Born Population (FinMonik, n = 6 836), conducted in Finland in 2018-19. SoB was assessed by the question “Which of the following areas or groups you feel you belong to?”, classified into 1) both Finns/local municipality and citizens of country of origin CCO (acculturation identity), 2) only Finns/local municipality (local identity), 3) only CCO (origin identity), 4) only Europeans, world citizens, religious, work-related or political group (other identity), and 5) none of the previous. PS was measured by using the MHI-5 (psychological strain: yes; no). Logistic regression was used to test the association between SoB and PS, with age, sex and country of origin as confounding variables. In the analyses, weights were used to reduce non-response bias.

Results

Compared to the acculturation identity group, PS was more common among those with local identity (OR = 1.60, p < 0.01), origin identity (OR = 1.99, p < 0.001) or other identity (OR = 3.33, p < 0.001) and those with no belonging to any of the groups presented (OR = 5.40, p < 0.001). The last group was more likely to experience PS than the acculturation identity group in all five country groups included in the analysis. Acculturation identity was associated with less PS especially for those born in EU-, EFTA- and North American countries.

Conclusions

Acculturation identity was strongly associated with less psychological strain, especially when compared with the group reporting no belonging to any of the groups presented.

Key messages

Sense of belonging is associated with mental health and should be studied more extensively among different foreign-born population groups. Identification with both the local people and one’s own country of origin should be supported.

Collecting high-quality survey data on hard-to-reach populations: lessons from Finland

Issue

Hard-to-reach populations refer to groups that may be difficult to involve in research. Minorities and persons with migration background (PMB) are often underrepresented in population-based surveys. This may lead to serious bias. Description of the problem: Several surveys on the health and wellbeing of hard-to-reach populations have been conducted in Finland since 2010. Strategies for collecting high-quality data have been identified in five surveys focused on specific migrant groups (Maamu n = 3000), the foreign-origin population (UTH n = 6000; FinMONIK n = 13650), newly-arrived asylum seekers (TERTTU n = 1087) and Finnish Roma (ROOSA n = 365). Also few routinely collected studies include indicators of ethnic background or origin (e.g. School Health Promotion study).

Results

Country of birth and foreign origin can be identified in Finland using register-based sampling. Snowball sampling was needed for the Roma population. Strategies to reach participants included information dissemination, translated questionnaires, multilingual personnel, telephone contacts and door-to-door visits. Stakeholders and participants were involved in planning and reporting. Participation rates as high as 70-80% were reached from register-based samples. Lessons: High-quality survey data can be collected on hard-to-reach populations. This requires adequate resources including multilingual personnel and researcher-participant trust. The cross-cultural validity of survey questions is critical; cognitive interviews can be used to improve cultural sensitivity. Researchers should be sensitive of sense of belonging, e.g. PMB may object being seen as “migrants”. Members of hard-to-reach populations should be involved in research, and not merely objects of a study.

Main messages

High participation rates can be achieved with adequate time, financial resources and established researcher-participant trust. Data collection should be inclusive and clearly benefit the individuals and populations in concern.

Injuries of adult asylum seekers in Finland: results of the 2018 TERTTU-health and well-being survey

Background

Injuries in refugees and asylum seekers result of accidents, violence or most extremely torture. Research in Finland has shown that many refugees experienced major traumatic events in their former home country, incl. permanent injuries. Our study provides new evidence on asylum seekers, a scarcely studied group.

Methods

Data was collected by structured face-to-face interviews. Healthcare staff asked adult participants if they had a bodily injury or scar. If yes, they pointed the location on a pictogram. Interviewers inquired if the injury was accidental or result of violence and if it happened before or during the fleeing trip. Injuries were classified as head (incl. brain) injuries, injuries of torso/extremities or other body areas.

Results

About half (47, 2 %) of 779 adults reported injuries, men more often than women (55,1 % vs. 35,3 %). Frequency was highest in 18-29-year olds. Close to all respondents (94 %) sustained injuries prior to their journey. Over one in five attributed injuries to accident (men 27 %, women 16 %). 16,6 % reported the torso/extremities as injury location, while 9,4 % had head injuries. Violence was cause of injury in over one fourth of cases (28 %). Every third male and every fifth female were violence victims, with no significant age difference. In both genders odds of violence exposure was highest in asylum seekers from sub-Saharan Africa - over 50 % attributed injury to violence. Violence victims had injuries of torso/extremities in 20,5%, and of the head in 15,3%. Head injuries were more frequent in > 40 year-old violence victims of both genders.

Conclusions

Injuries are common among adult asylum seekers in Finland. Prevalence of violence induced injury, especially in sub-Saharan Africans, is alarming. Training in violence victims’ management is required for professionals receiving asylum seekers. Information on injury severity and functional ability is needed for full impact assessment and service planning (incl. rehabilitation).

Key messages

Injuries are common among adult asylum seekers and often a result of violence, thus requiring of receiving services’ professionals skills and knowledge in violence victims’ management. Health examination protocols of asylum seekers should include injury severity assessment and impact on functional ability.

The role of unjust treatment for experienced unmet need for health care among Finnish Roma

Background

Finland is currently undergoing a major reform of social and health care, one aim of which, is to reduce inequalities between different population groups in access to care. Previous studies showed that Finnish Roma minority are more likely to experience unjust treatment in health services and other public services in comparison to other minorities in Finland. Unjust treatment may influence health behaviors, including the use of health services, by decreasing trust towards health professionals as well as decreasing social, emotional, and physical resources. This study examined the association between experienced unjust treatment in public services and self-assessed unmet need for health care among Roma in Finland.

Methods

We used data from the Roma health and wellbeing study (Roosa), conducted in Finland (2017-2018). The data was collected by the snowball method in different areas of Finland including a health examination and a structured interview. It covers 365 adults, and of those 223 (61.1%) were women. The outcome measure for unmet health care need was based on the question: “Do you feel that you have adequately received primary care services during the past 12 months?” Logistic regression was used to test the association between unjust treatment and unmet need for health care. Potential confounders were gender, age, marital status, education, employment and self-estimated health.

Results

The prevalence of unmet need for health care was 37.8 percent among men and 43.7 percent among women. Those who experienced unjust treatment in public services had higher odds (OR = 6.23; p < 0,001) for unmet need for health care than those who felt treated just. This association remained after adjustments for the confounders.

Conclusions

Over every third of the Finnish Roma experienced unmet need for health care. Unjust treatment seems to be a significant risk factor in access to care among Finnish Roma and its role needs further studies.

Key messages

Unjust treatment in public services is an indirect indicator of systematic and/or institutional discrimination. It is important to study the extent, nature and consequences of unjust treatment and discrimination to allow vulnerable groups to be taken into account better when renewing health services.

Mental health treatment gap in adults of Russian, Somali, and Kurdish origin in Finland

Background

Migration affects migrating persons’ health in many levels. Populations of migrant origin, and in particular refugees, are known to have an increased risk of mental ill health. Previous research from Finland has shown that the prevalence of mental health symptoms is significantly higher among Russian origin women and Kurdish origin men and women than in the general population. Building on prior research, we explore the prevalence of perceived need for mental healthcare among Russian, Somali, and Kurdish origin populations and compare this to the general population in Finland. Additionally, we present prevalence of mental health treatment gap in these groups.

Methods

We used data from the Finnish Migrant Health and Wellbeing Study (n = 1404) and the Health 2011 Survey (n = 1459). Prevalence was calculated using predicted margins (95% confidence level). P-value of less than 0.05 was considered significant. Mental health treatment gap was examined by constructing a combined variable of perceived need for mental health services and prevalence of service use.

Results

The perceived need for mental health services was higher in Kurdish origin persons (16%) and lower in Somali origin persons (<1%) than in the general population (8%). Both Kurdish origin men (11%) and women (20%) expressed more need for mental health services than men (4%) and women (11%) in the general population. The mental health treatment gap was highest in Russian origin women (10%) and Kurdish origin women (10%) and men (8%). For the general population, the treatment gap was only 1% (men 2 %, women <1%).

Conclusions

Untreated mental health problems are unjust, problematic and can be a source of great human suffering. Evidence from Finland shows that especially persons of Kurdish origin experience a mental health treatment gap. To expand coverage and reduce inequalities in health services, national development projects (e.g. PALOMA) have been launched to improve mental healthcare.

Key messages

Perceived need for mental health services is more common among certain foreign-born populations than the general population in Finland; this is in line with prior research on mental health symptoms. Untreated mental health problems are unjust, problematic and can be a source of great human suffering; evidence of mental health treatment gap should lead to improved access to mental health services.

Asylum seekers health and wellbeing (TERTTU) survey: study protocol for a prospective total population health examination survey on the health and service needs of newly arrived asylum seekers in Finland

INTRODUCTION

Health, well-being and health service needs of asylum seekers have emerged as urgent topics following the arrival of 2.5 million asylum seekers to the European Union (EU) between 2015 and 2016. However, representative information on the health, well-being and service needs of asylum seekers is scarce. The Asylum Seekers Health and Wellbeing (TERTTU) Survey aims to: (1) gather population-based representative information; (2) identify key indicators for systematic monitoring; (3) produce the evidence base for development of systematic screening of asylum seekers' health, well-being and health service needs.

METHODS AND ANALYSIS

TERTTU Survey is a population-based prospective study with a total population sample of newly arrived asylum seekers to Finland, including adults and children. Baseline data collection is carried out in reception centres in 2018 and consists of a face-to-face interview, self-administered questionnaire and a health examination following a standardised protocol. Altogether 1000 asylum seekers will be included into the study. Baseline data will be followed up with national electronic health record data encompassing the entire asylum process and later with national register data among persons who receive residency permits.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Coordinating Ethics Committee of the Helsinki and Uusimaa Hospital District. Participation is voluntary and based on written informed consent. Results will be widely disseminated on a national and international level to inform health and welfare policy as well as development of services for asylum seekers. Results of the study will constitute the evidence base for development and implementation of the initial health assessment for asylum seekers on a national level.

Frontal Cortex Myo-Inositol Is Associated with Sleep and Depression in Adolescents: A Proton Magnetic Resonance Spectroscopy Study

AIM

This study used proton magnetic resonance spectroscopy (1H MRS) to evaluate the neurochemistry of the frontal cortex in adolescents with symptoms of sleep and depression.

METHODS

Nineteen non-medicated adolescent boys (mean age 16.0 years; 9 clinical cases with depression/sleep symptoms and 10 healthy controls) underwent 1H MRS at 3 T. MR spectra were acquired from the anterior cingulate cortex (ACC), the dorsolateral prefrontal cortex, and frontal white matter. Concentrations of N-acetyl aspartate, total creatine, choline-containing compounds, total glutamine plus glutamate, and myo-inositol (mI) were compared in the 2 subgroups, and correlated with sleep and clinical measures in the total sample. Sleep was assessed with self-report questionnaires and ambulatory polysomnography recordings.

RESULTS

Concentrations of mI were lower in both frontal cortical regions among the depressed adolescents than in controls. No statistically significant differences in other metabolite concentrations were observed between the subgroups. Frontal cortex mI concentrations correlated negatively with depression severity, subjective daytime sleepiness, insomnia symptoms, and the level of anxiety, and correlated positively with total sleep time and overall psychosocial functioning. The correlations between mI in the ACC and total sleep time as well as daytime sleepiness remained statistically significant when depression severity was controlled in the analyses.

CONCLUSION

Lower frontal cortex mI may indicate a disturbed second messenger system. Frontal cortical mI may thus be linked to the pathophysiology of depression and concomitant sleep symptoms among maturing adolescents. Short sleep and daytime sleepiness may be associated with frontal cortex mI independently from depression.

Quality control for the first large areas of triple-GEM chambers for the CMS endcaps

The CMS Collaboration plans to equip the very forward muon system with triple-GEM detectors that can withstand the environment of the High-Luminosity LHC. This project is at the final stages of R&D and moving to production. An unprecedented large area of several 100 m2 are to be instrumented with GEM detectors which will be produced in six different sites around the world. A common construction and quality control procedure is required to ensure the performance of each detector. The quality control steps will include optical inspection, cleaning and baking of all materials and parts used to build the detector, leakage current tests of the GEM foils, high voltage tests, gas leak tests of the chambers and monitoring pressure drop vs. time, gain calibration to know the optimal operation region of the detector, gain uniformity tests, and studying the efficiency, noise and tracking performance of the detectors in a cosmic stand using scintillators.

A novel application of Fiber Bragg Grating (FBG) sensors in MPGD

We present a novel application of Fiber Bragg Grating (FBG) sensors in the construction and characterisation of Micro Pattern Gaseous Detector (MPGD), with particular attention to the realisation of the largest triple (Gas electron Multiplier) GEM chambers so far operated, the GE1/1 chambers of the CMS experiment at LHC. The GE1/1 CMS project consists of 144 GEM chambers of about 0.5 m2 active area each, employing three GEM foils per chamber, to be installed in the forward region of the CMS endcap during the long shutdown of LHC in 2108-2019. The large active area of each GE1/1 chamber consists of GEM foils that are mechanically stretched in order to secure their flatness and the consequent uniform performance of the GE1/1 chamber across its whole active surface. So far FBGs have been used in high energy physics mainly as high precision positioning and re-positioning sensors and as low cost, easy to mount, low space consuming temperature sensors. FBGs are also commonly used for very precise strain measurements in material studies. In this work we present a novel use of FBGs as flatness and mechanical tensioning sensors applied to the wide GEM foils of the GE1/1 chambers. A network of FBG sensors have been used to determine the optimal mechanical tension applied and to characterise the mechanical tension that should be applied to the foils. We discuss the results of the test done on a full-sized GE1/1 final prototype, the studies done to fully characterise the GEM material, how this information was used to define a standard assembly procedure and possible future developments.

Speeding Up and Parallelizing the GARFIELD++

Garfield++ is a toolkit for the simulation of particle detectors that use gas and semi-conductors as sensitive medium. It takes enormous amount of time to complete the simulation of complex scenarios such as those involving high detector voltages, gases with large gains, or electric field meshes with large number of elements. We observed that most of the simulation time is being consumed in finding the correct element in the electric field mesh. We optimized the element search operation and achieved significant boost in the speed up. In addition, We added the parallel computing support in the toolkit to simulate multiple events simultaneously over multiple machines. In this paper, we present our approach of speeding up the computations and benchmark results.

Factors associated with cervical cancer screening participation among immigrants of Russian, Somali and Kurdish origin: a population-based study in Finland

Background

Previous studies revealed low participation in cervical cancer screening among immigrants compared with non-immigrants. Only a few studies about factors associated with immigrants’ lower participation rates have been conducted in European countries that have universal access for all eligible women. Our study aimed to explore factors associated with cervical screening participation among women of Russian, Somali, and Kurdish origin in Finland.

Methods

We used data from the Migrant Health and Well-being Survey, 2010-2012. Structured face-to-face interviews of groups of immigrants aged 25-60 yielded 620 responses concerning screening participation in the previous five years. Statistical analysis employed logistic regression.

Results

The age-adjusted participation rates were as follows: among women of Russian origin 73.9% (95% CI 68.1-79.7), for Somalis 34.7% (95% CI 26.4-43.0), and for Kurds 61.3% (95% CI 55.0-67.7). Multiple logistic regressions showed that the most significant factor increasing the likelihood of screening participation among all groups was having had at least one gynecological check-up in the previous five years (Odds ratio [OR] = 6.54-26.2; p < 0.001). Other factors were higher education (OR = 2.63; p = 0.014), being employed (OR = 4.31; p = 0.007), and having given birth (OR = 9.34; p = 0.014), among Kurds; and literacy in Finnish/Swedish (OR = 3.63; p = 0.003) among Russians.

Conclusions

Our results demonstrate that women who refrain from using reproductive health services, those who are unemployed and less educated, as well as those with poor language proficiency, might need more information on the importance of screening participation. Primary and occupational healthcare services may have a significant role in informing immigrant women about this importance.

Cell cycle inhibition therapy that targets stathmin in in vitro and in vivo models of breast cancer

Stathmin is the founding member of a family of microtubule-destabilizing proteins that have a critical role in the regulation of mitosis. Stathmin is expressed at high levels in breast cancer and its overexpression is linked to disease progression. Although there is a large body of evidence to support a role for stathmin in breast cancer progression, the validity of stathmin as a viable therapeutic target for breast cancer has not been investigated. Here, we used a bicistronic adenoviral vector that co-expresses green fluorescent protein and a ribozyme that targets stathmin messenger RNA in preclinical breast cancer models with different estrogen receptor (ER) status. We examined the effects of anti-stathmin ribozyme on the malignant phenotype of breast cancer cells in vitro and in xenograft models in vivo both as a single agent and in combination with chemotherapeutic agents. Adenovirus-mediated gene transfer of anti-stathmin ribozyme resulted in a dose-dependent inhibition of proliferation and clonogenicity associated with a G2/M arrest and increase in apoptosis in both ER-positive and ER-negative breast cancer cell lines. This inhibition was markedly enhanced when stathmin-inhibited breast cancer cells were exposed to low concentrations of taxol, which resulted in virtually complete loss of the malignant phenotype. Interestingly, breast cancer xenografts treated with low doses of anti-stathmin therapy and taxol showed regression in a majority of tumors, while some tumors stopped growing completely. In contrast, combination of anti-stathmin ribozyme and adriamycin resulted in only a modest inhibition of growth in vitro and in breast cancer xenografts in vivo. Although inhibition of tumor growth was observed in both the combination treatment groups compared with groups treated with single agent alone, combination of anti-stathmin therapy and taxol had a more profound inhibition of tumorigenicity, as both agents target the microtubule pathway. Clinically, these findings are highly relevant because taxol is one of the most active chemotherapeutic agents in breast cancer. These studies provide the proof-of-principle that stathmin provides an attractive molecular target, which could serve as a primary focus of novel approaches to breast cancer.

Mental disorders in young adulthood

BACKGROUND

The effect of mental disorders may be particularly detrimental in early adulthood, and information on mental disorders and their correlates in this age group is important.

METHOD

A questionnaire focusing on mental health was sent to a nationally representative two-stage cluster sample of 1863 Finns aged 19 to 34 years. Based on a mental health screen, all screen-positives and a random sample of screen-negatives were asked to participate in a mental health assessment, consisting of the Structured Clinical Interview for DSM-IV (SCID-I) interview and neuropsychological assessment. We also obtained case-notes from all lifetime mental health treatments. This paper presents prevalences, sociodemographic associations and treatment contacts for current and lifetime mental disorders.

RESULTS

Forty percent of these young Finnish adults had at least one lifetime DSM-IV Axis I disorder, and 15% had a current disorder. The most common lifetime disorders were depressive disorders (17.7%) followed by substance abuse or dependence (14.2%) and anxiety disorders (12.6%). Of persons with any lifetime Axis I disorder, 59.2% had more than one disorder. Lower education and unemployment were strongly associated with current and lifetime disorders, particularly involving substance use. Although 58.3% of persons with a current Axis I disorder had received treatment at some point, only 24.2% had current treatment contact. However, 77.1% of persons with a current Axis I disorder who felt in need of treatment for mental health problems had current treatment contact.

CONCLUSIONS

Mental disorders in young adulthood are common and often co-morbid, and they may be particularly harmful for education and employment in this age group.

[Gender differences in brain development--correlation with the spectrum of psychiatric disturbances]

Maturation of brain structure has a different rhythm in girls and boys. From the viewpoint of cognitive processes, the first decade of life is the most important developmental stage after intrauterine life, cognitive functions will essentially develop also during the second decade. Gender differences have been noted already in early adolescence. Behavioral disturbances and substance abuse problems as well as attention-deficit disorders are more common in boys, whereas depression, anxiety and eating disorders are more common in girls. Regarding psychiatric morbidity, onset of puberty and late adolescence are periods of special vulnerability.

Sound processing in amateur musicians and nonmusicians: event-related potential and behavioral indices

To increase our understanding of auditory neurocognition in musicians, we compared nonmusicians with amateur band musicians in their neural and behavioral sound encoding accuracy. Mismatch negativity and P3a components of the auditory event-related potentials were recorded to changes in basic acoustic features (frequency, duration, location, intensity, gap) and abstract features (melodic contour and interval size). Mismatch negativity was larger in musicians than in nonmusicians for location changes whereas no statistically significant group difference was observed in response to other feature changes or in abstract-feature mismatch negativity. P3a was observed only in musicians in response to location changes. This suggests that when compared with nonmusicians, even amateur musicians have neural sound processing advantages with acoustic information most essential to their musical genre.

HCV infection and diabetes mellitus: influence of the use of finger stick devices on nosocomial transmission

An increased prevalence of hepatitis C virus (HCV) infection in patients with diabetes mellitus has suggested a link between these two conditions and the possibility of patient-to-patient HCV transmission during hospital admissions in diabetes units. We investigated the prevalence of HCV antibodies in 259 patients with diabetes mellitus consecutively admitted to our diabetic unit in 1998. The control group was composed of 14,100 volunteer blood donors. We divided the diabetic patients into two groups according to their HCV antibody status and also analysed patients for the following variables: age, disease duration, diabetes treatment, previous hospital admissions in a diabetes unit and use of finger stick devices. Anti-HCV antibodies were detected in 8 diabetic patients and 6 blood donors (3.09% vs 0.04%, p < 0.001). No differences were observed between anti-HCV-positive and anti-HCV-negative diabetic patients in terms of mode of treatment, previous hospital admissions in a diabetic unit and use of finger stick devices for capillary blood sampling. Our findings indicate that these medical practices play no role in nosocomial transmission of HCV in diabetic patients.

Possible role for oxygen free radicals in the regulation of renal nitric oxide synthesis and blood flow

BACKGROUND

This study examines the hypothesis that oxygen radicals down-regulate renal nitric oxide synthesis and contribute to renal vasoconstriction after hemorrhage/reperfusion injury.

METHODS

Arterial pressure and renal artery blood flow were measured in anesthetized rats subjected to sham or hemorrhage (30 mm Hg for 30 minutes) followed by blood reperfusion without or with superoxide dismutase, an oxygen radical scavenger. Animals were sequentially injected with 10 mg/kg NG-nitro-L-arginine methyl ester (L-NAME), a nitric oxide synthase inhibitor, and 200 mg/kg and 400 mg/kg L-arginine, a nitric oxide precursor.

RESULTS

The L-NAME treatment increased arterial pressure and decreased renal artery blood flow whereas L-arginine decreased arterial pressure and decreased renal blood flow in the sham animals. Hemorrhage/reperfusion injury attenuated the pressure and renal blood flow changes following L-NAME and L-arginine treatment, which was reversed by superoxide dismutase.

CONCLUSIONS

These data suggest that oxygen radicals contribute to the regulation of renal nitric oxide synthesis, contributing to renal artery vasoconstriction following hemorrhage/reperfusion injury.

Oxygen free radicals regulate splanchnic nitric oxide synthesis and blood flow

This study examines the hypothesis that oxygen radicals down-regulate splanchnic nitric oxide synthesis and contribute to splanchnic vasoconstriction following hemorrhage/reperfusion injury. Anesthetized rats underwent placement of flow probes around the superior mesenteric artery and abdominal aorta. Animals were bled to 30 mmHg for 30 min, reperfused without or with superoxide dismutase, an oxygen radical scavenger, 15 min before reperfusion and compared with sham-treated rats. Animals were sequentially treated with the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME) at 10 mg/kg and L-arginine, a nitric oxide precursor, at 200 mg/kg or 400 mg/kg. L-NAME increased systemic pressure and decreased superior mesenteric artery blood flow whereas L-arginine decreased arterial pressure and increased superior mesenteric artery blood flow in the sham animals. Hemorrhage/reperfusion injury attenuated the pressure and superior mesenteric artery blood flow changes following L-NAME and L-arginine dosing, which was reversed by superoxide dismutase treatment. These data suggest that oxygen free radicals regulate splanchnic nitric oxide synthesis, thus contributing to splanchnic vasoconstriction following hemorrhage/reperfusion injury.

Mitral atresia with a large left ventricle and an underdeveloped or absent right ventricular sinus: clinical profile, anatomic data and surgical considerations

In mitral atresia with a large left ventricle, the tricuspid valve is either straddling and biventricular or entirely left ventricular. To learn how to assess the identity of the tricuspid valve in such cases 15 heart specimens were examined as well as the echocardiograms of 10 living patients. When the right ventricular sinus was underdeveloped (11 cases), a straddling tricuspid valve was present; when it was absent (14 cases), the tricuspid valve was entirely left ventricular. Regardless of biventricular or exclusively left ventricular attachments, the tricuspid valve was tricommissural (at postmortem examination or on echocardiography) in 22 cases (88%). Its chordal attachments showed considerable variations but were usually paraseptal or on the ventricular septal crest or conal septum. When biventricular, the tricuspid valve straddled through an inlet ventricular septal defect. Clinical or anatomic evidence, or both, of tricuspid regurgitation was present in 14 cases (56%). It is concluded that 1) the identity of the atrioventricular valves is reflected in their chordal attachments more accurately than in their leaflet morphology and depends primarily on the type of ventricular loop present; 2) as a rule, the tricuspid valve is right-sided in D-looped and left-sided in L-looped ventricles; 3) valve identity expressed as the number and position of the papillary muscle attachments is generally recognizable echocardiographically and can be used to diagnose the type of ventricular loop that is present; and 4) the presence and degree of tricuspid regurgitation deserve attention when choosing optimal palliative surgery.

Arterial switch operation for simple and complex TGA--indication criterias and limitations relevant to surgery

Since 1983, 505 patients underwent the arterial switch operation (ASO). 326 (28 days) had transposition of the great arteries with an intact ventricular septum (TGA/IVS) und 179 had a ventricular septal defect (TGA/VSD). Mean age at ASO was 7 +/- 5 days. Total mortality in the neonatal group was 7%. In the last 150 neonates, there was no operative mortality. Two late deaths were due to coronary obstruction 6 and 7 weeks after ASO. Cardiac catherisation in 106 late survivors revealed a mean gradient form RV to PA of 20 +/- 20 mmHg, and from LV to aorta of 5 +/- 8 mmHg. Mean PA pressure was 13 +/- 4 mmHg; enddiastolic pressure in the left ventricle was 8 +/- 3 mmHg. Cardiac index was 4.0 +/- 1.2 L/min. Sinus node recovery time was normal in 97%. Asymptomatic occlusion of a coronary artery was present in 3 patients. Aortic regurgitation was moderate in 1%. Rapid two-stage ASO (preliminary PA banding and shunt followed by ASO after 7 days) was carried out successfully in 29/30 patients with TGA/IVS, the oldest being 28 months of age. The ASO, as a primary operation, is our treatment of choice for neonates with TGA/IVS and TGA/VSD. The rapid two-stage approach is applicable for older patients with TGA/IVS.

Results of the Senning operation for transposition of the great arteries with intact ventricular septum in neonates

In spite of an adequate balloon atrial septostomy, some neonates (less than 28 days of age) with transposition of the great arteries and intact ventricular septum (TGA, IVS) remain hypoxemic and acidotic and require operative treatment. Our entire experience with the Senning operation in neonates with TGA, IVS is reviewed. From March 1978 to March 1983 there were 104 infants who underwent the Senning operation for TGA, IVS. Of these, 19 were neonates (18%). The mean age at operation was 12 days (2 to 24) and mean weight was 3.52 kg (3 to 4.38). Two died early (10%) and one died late (5%). The last 16 are alive and well. Causes of early mortality were sepsis and severe obstruction of the superior vena cava. The cause of late mortality was severe pulmonary venous obstruction. Among the 16 survivors, postoperative courses, both early and late, have been remarkably benign. Ten patients have undergone postoperative cardiac catheterization (mean follow up 17 months). Two (12%) had severe pulmonary venous obstruction (one diagnosed by two-dimensional echocardiography), but both were successfully repaired. Atrial shunt was noted in two patients (12%), one of which underwent elective repair. Five infants have dynamic subvalvular pulmonary stenosis of various gradients (9 to 93 mm Hg). One infant has mild tricuspid regurgitation. There are no cases of superior vena caval obstruction or right ventricular dysfunction. Twenty-four hour electrocardiographic monitoring (mean follow-up 25 months) showed predominant normal sinus rhythm in 15 infants and predominant junctional rhythm in one.(ABSTRACT TRUNCATED AT 250 WORDS)

Subclavian arterioplasty for the ipsilateral subclavian-to-pulmonary artery shunt

A new technique is described to avoid kinking and improve flow in the ipsilateral subclavian-to-pulmonary artery shunt. Experience with this procedure is reviewed in 35 infants and children with a variety of cyanotic congenital heart disease, including 10 with tricuspid atresia. Of these, 17 had had previous shunts: a Waterston shunt in six, a Glenn shunt in six, and a contralateral Blalock-Taussig shunt in five. The mean age was 5.6 years (range, 1 day to 16 years), and the mean follow-up was 24 months (range, 11 months to 4.5 years). There were no early deaths (less than 30 days), but there were two late deaths. There were three shunt failures at 2 weeks, 1 month, and 10 months; two of the failures were in infants aged 1 day and 4 days at operation. There were no late shunt failures. The patency by the life table method was 91.4% at 6 months, 88.5% at 1 year, with no further drop-off. It is concluded that subclavian arterioplasty can be performed safely and offers improved shunt patency in comparing to the ipsilateral Blalock-Taussig shunt.

Considerations in the development of artificial heart valve substitutes for use in infants in small children

Experimental studies carried out in our laboratory suggest that it is possible to develop a family of stent-supported tissue valve substitutes suitable for use in tissue and annuli of the hearts of small children in tissue annulus sizes ranging from 12 to 22 mm. Either glutaraldehyde-preserved, stent-supported primate tissue aortic valves or tissue leaflet valves constructed from dura mater preserved in 98 per cent glycerine can be used. In both instances, hemodynamics assessment of the valve substitutes in a mock circulation indicated that function was acceptable at the cardiac outputs normal for infants and children during the first few years of life. Stent-supported dura mater valves 16 nm. in diameter have been used to replace the mitral valve in 2 infants 7 and 8 months of age with complete atrioventricular canal defects and mitral regurgitation, one of whom survives with demonstratable satisfactory hemodynamic function of the valve substitute.

Pulmonary valvulotomy under inflow stasis for isolated pulmonary stenosis

One hundred ten patients were operated upon between 1961 and 1972 for isolated pulmonary stenosis by the inflow stasis technique. Analysis of the preoperative and postoperative clinical and catheterization data define the role of inflow stasis as an acceptable method of pulmonary valvulotomy except in relieving stenosis due to a dysplastic pulmonary valve. Patient ages ranged from 2 days to 36 years. All underwent preoperative catheterization and 69 (63%) were restudied postoperatively. Mean preoperative and postoperative peak systolic gradients were 93 and 23 mm Hg, respectively. Mean valve areas before and after operation were 0.38 and 1.10 cm2/m2. Operative mortality was 3.6% (4 patients), and there was 1 late death. Two of the dead were children 2 and 9 days old, respectively. Four patients required reoperation for residual gradients; 2 had dysplastic pulmonary valves. The overall results were excellent or good in 78%, fair in 15%, and poor in 7%. Patients with dysplatic pulmonary valves were in the poor or fair group, and it is recommended that the inflow stasis technique not be used for this type of pulmonary stenosis. The excellent surgical exposure, adequate time for valvulotomy, low morbidity, and freedom from problems of cardiopulmonary bypass are reasons for continued use of this technique for treatment of selected patients with pulmonary valve stenosis.

Repair of tetralogy of Fallot after catheterization-induced complete heart block

The case of a four-year-old boy with tetralogy of Fallot who developed complete heart block during cardiac catheterization and subsequently underwent surgical repair in the presence of heart block is presented. Return to normal sinus rhythm occurred on the 11th postoperative day, and the manner in which increased atrioventricular conduction appeared was documented with the use of a continuous Holter monitor. Placement of a temporary transvenous pacemaker, systemic heparinization in the preoperative period, and the insertion of a permanent epicardial wire during surgery were performed.

Banding of the pulmonary artery. Results in 111 children

The results of banding of the pulmonary artery in 111 children with cardiac malformations associated with excessive pulmonary blood flow are presented. Thirty-three of these children died, eleven either of late band complications or after a corrective operation. Patients with ventricular septal defect represent the largest group of malformation among the 111 patients.

The overall mortality for banding in patients with isolated ventricular septal defect is 10%, as compared to 36% in patients with ventricular septal defect complicated by an associated lesion. In all infants with ventricular septal defect banded under age 3 months the mortality is 59%, as compared to a mortality of 21% in those banded after age 3 months and only 7% if banded after age 1 year. The overall mortality figures for pulmonary arterial banding have not changed appreciably since 1966; future improvement in banding mortality will depend on improved postoperative management of these infants.

Serial hemodynamic studies in patients banded under the age of 2 years have shown a fall in the pulmonary resistance toward normal, with none showing a progression of pulmonary vascular disease. In several patients thickening of the pulmonary valve occurred as a complication of banding.