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Two-dimensional Doppler echocardiography was used to diagnose congestive heart failure in a fetus with a large sacrococcygeal teratoma. Ultrasound performed for size-date inconsistency revealed a 27.5-week fetus with hydrops and a large solid and cystic mass in the sacral region. Fetal echocardiography showed dilated ventricles and a pericardial effusion; Doppler ultrasound demonstrated increased velocities and volume flows, along with tricuspid and mitral regurgitation. At delivery, the mass was bleeding actively, the amniotic fluid was markedly bloody, and the neonatal hematocrit was 10%. We postulate that intrauterine hemorrhage from the teratoma led to anemia and high-output cardiac failure confirmed by Doppler echocardiography, and suggest that all fetuses with sacrococcygeal teratomas be evaluated by two-dimensional Doppler echocardiography to detect the presence of congestive heart failure, in order to allow well-timed therapeutic interventions.

For the first time, much of the significant literature on occupational therapy has been gathered in one place so that clinicians, students, and scholars can use the collection for study, research, or browsing. The initial efforts have provided a rich resource on the history and evaluation of occupational therapy. Occupational therapy practitioners, educators, and researchers are encouraged to make use of library resources and to support the continued development of the library through donations of old and new materials. Interested persons may write or call the Occupational Therapy Library through the Association address or telephone number.

The prenatal diagnosis of fetal cardiac disease has become increasingly accurate as the technology of ultrasound has improved. Although two-dimensional real-time ultrasound remains the primary method of diagnosis, Doppler blood flow velocity estimates can provide valuable pathophysiologic information to support the anatomic diagnosis. We present six cases in which Doppler studies contributed to the accuracy of the diagnosis of fetal heart disease, including tetralogy of Fallot, right and left ventricular hypoplasia, atrioventricular canal defect, double-outlet right ventricle, and pulmonic stenosis. Velocities in these cases are compared with those in normal fetuses. If Doppler flow velocities are not consistent with the observed morphologic changes, further observations are indicated. Inasmuch as most anatomical heart lesions result in altered flow patterns, Doppler investigations of intracardiac and extracardiac flow should be a routine component of the fetal echocardiogram when structural abnormalities are found.

The study of arrhythmias enables the clinician not only to treat and effectively prevent some types of fetal morbidity, but also to understand the normal human fetal physiology. It can be anticipated that the study of arrhythmias in the fetus will expand, if the work currently performed in the child and adult is any indication.

With the combined use of two-dimensional ultrasound and Doppler echocardiography, noninvasive examination of the human fetal heart and circulation has recently become possible. These techniques were employed to investigate diastolic atrioventricular valve flow in the fetal heart in 120 fetuses studied between 17 and 42 weeks of gestation. Two-dimensional ultrasound was used to examine fetal and intrauterine anatomy, and estimates of gestational age were made based on biparietal diameters and femur lengths. Doppler echocardiography was performed with a 3.5 or 5 MHz Doppler sector scanner. Flow velocity patterns were obtained through the tricuspid and mitral valves during diastole. Peak flow velocity during late diastole or atrial contraction (A) was compared with peak flow velocity during early diastole (E) in four groups of fetuses: Group 1, 17 to 24 weeks of gestation; Group 2, 25 to 30 weeks; Group 3, 31 to 36 weeks; and Group 4, 37 to 42 weeks. The ratio of A to E decreased significantly as gestational age advanced, from 1.56 +/- 0.06 (+/- SE) to 1.22 +/- 0.03 across the tricuspid valve (p less than 0.001) and from 1.55 +/- 0.04 to 1.22 +/- 0.06 across the mitral valve (p less than 0.001). In tricuspid valve measurements, peak flow velocity during early diastole increased from 26.3 +/- 2.0 cm/s in Group 1 to 36.5 +/- 1.7 cm/s in Group 4 (p less than 0.001), whereas peak flow velocity during atrial contraction did not change.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies in instrumented adults have shown an association between Doppler echocardiography-derived atrioventricular valve deceleration times and ventricular function. To determine how gestational age affects deceleration time in the tricuspid and mitral valve, pulsed Doppler ultrasonographic examinations were performed in 54 normal human fetuses. In addition, 26 fetuses with growth retardation and the absence of end-diastolic Doppler velocities in the umbilical artery were examined. Measurements were obtained from strip chart recordings; between three and five beats were used to obtain an average heart rate, ratio of peak velocity at atrial contraction to peak velocity in early diastole, and deceleration time in early diastole. Deceleration times increased during gestation from 86 +/- 27 to 116 +/- 18 msec in the tricuspid valve and from 98 +/- 25 to 132 +/- 21 msec in the mitral valve. Fetuses with growth retardation and the absence of end-diastolic Doppler velocities in the umbilical artery had longer deceleration times than those of normal fetuses (p less than 0.01). The increase in deceleration time across both atrioventricular valves in normal fetuses may be related to heart rate, an increased rate of ventricular relaxation, or an increase in ventricular compliance. The fetuses with intrauterine growth retardation and the absence of end-diastolic velocities in the umbilical artery have abnormally increased deceleration times; in the abnormal fetus this may be a result of impaired ventricular relaxation or decreased ventricular compliance.

Occupational therapists have used many media and methods over the years to achieve the therapeutic potential of occupational therapy. Yet the reasons for selecting a specific medium or method frequently have been lost or changed without consideration of the result to the therapeutic situation. When neither therapist nor patient understands fully the rationale for a medium or method, the therapeutic potential of that medium or method may be compromised. The author suggests there are eight factors that influence the selection and discarding of media and methods in the practice of occupational therapy. The effects of the eight factors can be summarized in 14 assumptions. Three examples--arts and crafts, sanding blocks, and work-related programs--are used to illustrate the factors and assumptions. It is suggested that improved analysis of occupations based on values and interests could reduce the separation of meaning and purpose in the selection and discarding of media and methods used in occupational therapy practice.

During recent years, Doppler ultrasound has become an instrument with which the fetal and neonatal cardiovascular system can be examined noninvasively. In fetuses with suspected cardiac anomalies, Doppler examinations can be used to complement two-dimensional and M-mode studies. Information derived from human fetal intracardiac studies has established that the human fetal heart is right-heart dominant, less compliant than the adult heart, and changes with advancing gestation. Much work remains to be performed to use this information to better manage ongoing pregnancies, and to optimize transition to neonatal life.

The association of congenital heart block with maternal connective tissue disease and autoimmunity has been recently reported. Two cases of heart block were diagnosed in utero at 23 and 24 weeks' gestation. Both mothers had extensive workups for connective tissue disease that were negative. Two-dimensional and Doppler echocardiography were performed in utero and both infants had left atrial isomerism, atrioventricular canal defects, and severe hydrops in addition to heart block. Review of the recent literature identifies a subset of congenital heart block in which the mothers have no evidence for connective tissue disease, and the fetus or neonate has complex cardiac malformations and hydrops. The common features in these babies are atrioventricular canal defects and isomerism. No reports of congenital heart disease among the children of mothers with connective tissue disease fit this description. Our recent experience and literature review emphasize the previously known association between congenital heart block and congenital heart disease. This association is especially important in light of the poor prognosis for this group of fetuses and neonates.

Desipramine and its metabolite 2-hydroxydesipramine were measured in the milk of a nursing mother and in the plasma of the mother and infant during administration of 300 mg/day of desipramine to the mother. Similar concentrations of both compounds were found in maternal plasma and milk. A pharmacokinetic plot of the milk over 24 hours showed the expected rise and fall of the substances following a single nighttime dose. Neither parent compound nor metabolite could be detected in the infant's serum even though the measurements were made shortly after peak ingestion by the infant. Furthermore, no clinical signs of toxicity were observed in the infant after 3 weeks of treating the mother with desipramine.

Forty-four fetuses with pericardial effusions have been identified by ultrasonographic examinations. The clinical histories and courses of these patients were reviewed. At least eight different clinical features accompanied and were probably responsible for the pericardial effusions. The most common cause of a fetal pericardial effusion was heart failure (13 fetuses). Fetal renal cystic dysplasia with oligohydramnios and other anomalies was present in six fetuses. Four of this group had microscopic evidence of pericarditis on postmortem examination. Fetal pericardial effusions are always a manifestation of another disease process often presenting as fetal hydrops. Some pericardial effusions are transient. The etiologic origin of fetal pericardial effusions differs from that in the child or adult.

Eighty-six fetuses of 21-41 weeks' gestation with arrhythmias were studied with ultrasound and heart rate monitoring. The type of arrhythmia was identified by M-mode studies and was confirmed by postnatal electrocardiogram in 70 infants. The most common arrhythmia was premature atrial contractions (76), followed by premature ventricular contractions (five), paroxysmal supraventricular tachycardia (four), and atrial fibrillation/flutter (one). Doppler echocardiography was performed in 54 fetuses to measure flow velocities across the atrioventricular and semilunar valves. After isolated premature atrial and ventricular contractions, post-extrasystolic potentiation was demonstrated by an increase in fractional shortening (N = 32) of 49 +/- 6% in the right ventricle and 64 +/- 7% in the left ventricle. When post-extrasystolic beats were compared with normal beats, Doppler-determined time-velocity integrals increased 43% across the tricuspid valve, 41% across the mitral valve, 34% across the pulmonary valve, and 38% across the aortic valve. Mean velocity increased significantly after conversion to normal sinus rhythm in the five fetuses with supraventricular tachycardia (P less than .05). By studying the physiologic consequences of fetal arrhythmias using two-dimensional Doppler and M-mode ultrasound, we have documented the presence of post-extrasystolic potentiation after premature contractions, the existence of the Frank-Starling mechanism, and an increase in mean velocity (and therefore in cardiac output) after conversion of fetal tachyarrhythmias to normal sinus rhythm.

1. Knowledge of basic pharmacokinetic parameters may help the clinician to optimize drug treatment regimen. 2. For some psychotropic drugs (e.g. lithium and some antidepressants) a good correlation exists between plasma levels and therapeutic or toxic effects. 3. "Optimum" steady state levels can now be predicted from single dose blood level data of some drugs (lithium, nortriptyline, desipramine). 4. Altered pharmacokinetics in elderly and children have to be taken into consideration in treatment with psychotropic drugs. 5. With development of suitable drug assays, plasma level control of therapy is becoming a part of a good clinical practice.

This study was designed to locate and document serial literature on occupational therapy published since 1900. Emphasis is placed on finding articles on occupational therapy or by occupational therapists from sources other than those normally associated with the professional journals. Multiple sources were used including print indexes, online databases, occupational therapy bibliographies, and tables of contents or yearly indexes. Almost 7,000 articles were identified, not including those published in foreign journals. Occupational therapy publications have increased steadily since 1900, with the most rapid increase during the 1970s and 1980s when five new occupational therapy journals were initiated. Suggestions for formulating search strategies are included.

Plasma levels of desipramine (DMI) and the unconjugated form of its principal metabolite 2-hydroxydesipramine (OH-D) were measured under steady-state conditions in nine depressed inpatients during treatment with 75 mg DMI every 12 hr and after at least 1 wk of an increased dose of DMI (after steady state). When DMI dosage was raised after an initial steady state had been reached, the rise in plasma DMI level was proportionately greater than the increase in dosage, suggesting saturation of DMI elimination pathways. Levels of OH-D rose in proportion to dose, suggesting saturation of DMI elimination by 2-hydroxylation could not explain DMI plasma level changes. In contrast, there were no dose-dependent effects on the disposition of amitriptyline or its metabolite nortriptyline in subjects receiving the same amitriptyline dose.

Two-dimensional and pulsed Doppler ultrasound techniques were used to examine 87 fetuses between 17 and 41 weeks' gestation in order to compare pulmonary artery and aortic outflow diameters, mean and maximal flow velocities, and transvalve flows. For purposes of analysis, fetuses were divided into two groups: those less than 31 weeks, and those of 31 weeks or more. Diameters of the pulmonary artery and aortic outflow region increased with advancing gestational age (P less than .001), while mean and maximal Doppler flow velocities did not change. Transvalve volume flow increased across both regions (pulmonary artery from 381 +/- 12 mL/minute to 530 +/- 13 mL/minute and aortic outflow from 286 +/- 10 mL/minute to 410 +/- 13 mL/minute, P less than .001) with advancing gestation. Pulmonary artery diameters were larger than aortic outflow diameters in both groups (P less than .01), while mean Doppler flow velocities were not significantly different. Maximal Doppler flow velocities were greater in the aorta than in the pulmonary artery (P less than .001), and transvalve flow was greater across the pulmonary artery than the aorta in both groups (P less than .05, ratio 1.3:1). This work demonstrates differences in fetal pulmonary artery and aortic outflow anatomy and physiology that must be considered in evaluating studies of fetal cardiac physiology.

Umbilical artery Doppler blood flow velocity studies were used to identify 14 fetuses with absent flow during diastole to determine the significance of absent umbilical artery diastolic flow. Outcomes of these fetuses were recorded, and the associated intracardiac Doppler changes were identified in 12 of them. Maximal and mean intracardiac flow velocities were measured, and volume flows through the right (tricuspid valve, pulmonary valve) and left (mitral valve, aortic valve) sides of the heart were compared. Ratios of intracardiac peak flow velocity in late diastole to peak flow velocity in early diastole were calculated. Eleven fetuses had intrauterine growth retardation, and four had multiple congenital anomalies. Fetuses with no diastolic flow in the umbilical artery had increased volume flow across the tricuspid and pulmonary valves compared with normal fetuses of similar weights. The ratio of right-sided to left-sided volume flow in the heart (2.15:1) was increased compared with values in normal fetuses (1.33:1, p less than 0.01). The ratio of late diastolic to early diastolic peak flow velocities across the mitral valve was decreased (p less than 0.01). Absent umbilical artery diastolic flow is associated with increased tricuspid and pulmonary valve volume flow and changes in mitral flow velocity patterns, which suggests that there are alterations in left ventricular function.