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The Single Ventricle Reconstruction Trial randomised neonates with hypoplastic left heart syndrome to a shunt strategy but otherwise retained standard of care. We aimed to describe centre-level practice variation at Fontan completion.
Centre-level data are reported as median or median frequency across all centres and range of medians or frequencies across centres. Classification and regression tree analysis assessed the association of centre-level factors with length of stay and percentage of patients with prolonged pleural effusion (>7 days).
The median Fontan age (14 centres, 320 patients) was 3.1 years (range from 1.7 to 3.9), and the weight-for-age z-score was −0.56 (−1.35 + 0.44). Extra-cardiac Fontans were performed in 79% (4–100%) of patients at the 13 centres performing this procedure; lateral tunnels were performed in 32% (3–100%) at the 11 centres performing it. Deep hypothermic circulatory arrest (nine centres) ranged from 6 to 100%. Major complications occurred in 17% (7–33%). The length of stay was 9.5 days (9–12); 15% (6–33%) had prolonged pleural effusion. Centres with fewer patients (<6%) with prolonged pleural effusion and fewer (<41%) complications had a shorter length of stay (<10 days; sensitivity 1.0; specificity 0.71; area under the curve 0.96). Avoiding deep hypothermic circulatory arrest and higher weight-for-age z-score were associated with a lower percentage of patients with prolonged effusions (<9.5%; sensitivity 1.0; specificity = 0.86; area under the curve 0.98).
Fontan perioperative practices varied widely among study centres. Strategies to decrease the duration of pleural effusion and minimise complications may decrease the length of stay. Further research regarding deep hypothermic circulatory arrest is needed to understand its association with prolonged pleural effusion.
John F. Kennedy’s most basic goal as president of the United States was to reach a political understanding with the Soviet Union. That understanding would be based on a simple principle: the United States and the Soviet Union were both very great powers and therefore needed to respect each other’s most basic interests. The US government was thus prepared, for its part, to recognize the USSR’s special position in Eastern Europe. The United States would, moreover, see to it that West Germany would not become a nuclear power. In exchange, the Soviets would also have to accept the status quo in Central Europe, especially in Berlin. If a settlement of that sort could be worked out, the situation in Central Europe would be stabilized. The great problem that lay at the heart of the Cold War would be resolved.
But to reach a settlement based on those principles, Kennedy had to get both the USSR and his own allies in Europe to accept this sort of arrangement. The Soviets, however, were not particularly receptive when it became clear to them, beginning in mid-1961, what the president had in mind. The Americans, in their view, were making concessions because they were afraid the Berlin crisis would lead to war. Why not see what more they might get by keeping the crisis going?
In January 1963, Konrad Adenauer, the chancellor of the Federal Republic of Germany, came to Paris to sign a treaty of friendship with France. This was an event of considerable political importance. The German government, it seemed, had decided to form a kind of bloc with the France of President Charles de Gaulle, a country which for some time had been pursuing a policy with a distinct anti-American edge. Indeed, just one week before Adenauer's visit, de Gaulle had risen up against the United States. He had announced that France was going to veto Britain's entry into the European Common Market. If the British were allowed in, de Gaulle argued, continental Europe would eventually be absorbed into a “colossal Atlantic Community, dependent on America and under American control,” and this France would not permit. The German government seemed to share de Gaulle's sentiments. How else could its willingness to sign a treaty with France at that particular point possibly be interpreted?
The Americans were enraged by what France and Germany had done, and the Kennedy administration, then in power, decided to take a very hard line. The Europeans, President Kennedy felt, could not be expected to pursue a pro-American policy simply because of what the United States had done for them in previous years.