Endocardial Pacemaker Implantation in Neonates and Infants

Transvenous pacemaker lead implantation is the preferred method of pacing in adult patients. Lead performance and longevity are superior and the implantation approach can be performed under local anaesthetic with a very low morbidity. In children, and especially in neonates and infants, the epicardial route was traditionally chosen until the advent of smaller generators and lead implantation techniques that allowed growth of the child without lead displacement. Endocardial implantation is not universally accepted, however, as there is an incidence of venous occlusion of the smaller veins of neonates and infants with concerns for loss of venous access in the future. Growing experience with lower profile leads, however, reveals that endocardial pacing too can be performed with low morbidity and good long-term results in neonates and infants

Studies of the laser thermal probe in cardiovascular disease

The initial use of optical fibres to transmit laser energy intravascularly was accompanied by a high rate of perforations and the production of inadequate vascular channels when used for recanalisation. The laser thermal probe - in which all laser energy is converted into heat by a metal cap at the tip of the fibre, prior to tissue application - was one of the earliest modifications designed to overcome these problems. The studies in this thesis were concerned with the application of the laser thermal probe to percutaneous peripheral and coronary artery angioplasty and His bundle ablation. In vitro studies were commenced in March 1987 when the first (argon) laser generator was installed in the cardiac catheterisation laboratory at Guy's Hospital and these were followed by clinical studies in three groups of patients: nine with peripheral artery occlusions, three with coronary artery stenoses and four with supraventricular arrhythmias using either argon or Nd-YAG energies. Suggestions that enhanced safety might be possible with on-line monitoring and/or control of the probe temperature were studied by recording the temperature responses in simulated circulations at flow rates observed clinically. The highly variable temperatures recorded in blood indicate that these measures are unlikely to contribute to improvements in either efficacy or clinical safety. An earlier report of successful peripheral artery recanalisation using the laser thermal probe was confirmed in the patients studied here, though a learning curve was evident. Coronary laser angioplasty had also been performed in a few patients with a similar device but without as much success. A more flexible "over the wire" laser probe was assessed here, first in cadaver coronary arteries and then in three patients undergoing coronary angioplasty. The lack of success seen with this laser thermal probe relates to the considerable differences found between peripheral and coronary arteries: percutaneous accessibility, vessel size and the susceptibility to thermal injury being the most important. These aspects and subsequent developments in coronary laser angioplasty are discussed further. The final chapter considers a hitherto new area for laser thermal probe application the interruption of arrhythmia circuits. Cadaver and electrophysiological studies indicated that ablation of the bundle of His might be possible with this device - without the need for a general anaesthetic. The course of the first patient ever to undergo this procedure is described, as well as the implications for percutaneous His bundle ablation using other energy sources

The Right of All Children to Grow Up with a Family under International Law: Implications for Placement in Orphanages, Residential Care, and Group Homes

This article describes the right of all children to live and grow up in a family as it has evolved thirty years after the adoption of the U.N. Convention on the Rights of the Child (CRC) and since the 2006 adoption of the U.N. Convention on the Rights of Persons with Disabilities (CRPD). The article examines the implications of this right for the millions of children placed in orphanages, residential care, and group homes around the world. The CRC favors the placement of children with a family, but it does allow for the placement of children in suitable institutions when families are unavailable. In General Comment No. 9, the U.N. Committee on the Rights of the Child states that institutions should be transformed into smaller residential facilities and used only as a last resort. The United Nations Guidelines on Alternative Care calls for the elimination of large institutions but also allows for long-term placement in smaller residential homes. The more recently adopted U.N. Convention on the Rights of Persons with Disabilities (CRPD) now creates stronger protections through a combination of Article 23 (respect for home and family) and Article 19 (living independently and being included in the community). In 2017, the U.N. Committee on the Rights of Persons with Disabilities adopted General Comment No. 5, stating that, for children, the right to community integration entails a right to live and grow up with a family. The Committee stated that placement in a family-like residence and group home is not a substitute for the right to a family under the CRPD. The protections established in the CRPD are consistent with new research revealing that institutions and residential care are inherently detrimental to children. Experience shows that all children, no matter how severe their disability, can and should receive the support and protection they need to live and grow up with a family. This article makes the case that the protections recognized by the CRPD apply to all children - not just children with disabilities. To implement this right, governments are under an obligation to create the range of supports needed so that all children can live in families and not institutions, residential care, or group homes. Protections for the family under the CRC should reflect these developments in international law and knowledge about child development. Article 41 of the CRC recognizes evolving international standards for the protection of children. Thus, the Committee on the Rights of the Child should update General Comment No. 9 to comply with new legal standards that protect the right of all children to live and grow up with a family. The U.N. Guidelines for Alternative Care can be preserved, so long as they are used in a manner consistent with the requirements of the CRPD and are not used to justify permanent placement in group homes or other residential facilities