SUMMARY Of the first 250 heart and 35 heart and lung transplant recipients at Papworth Hospital, Cambridge, who survived for more than one month after transplantation, 217 heart and 33 heart and lung patients were investigated serologically for evidence of Toxoplasma gondii infection. Six patients acquired primary Tgondii infection, most probably from the donor organ. Five patients experienced Tgondii recrudescence, two of whom had recovered from primary infection a few years earlier. Two patients died from primary Tgondii infection and the severity of symptoms in the other patients with primary infection was related to the amount of immunosuppressive treatment. Prophylaxis with pyrimethamine (25 mg a day for six weeks) was introduced for Tgondii antibody negative transplant recipients who received a heart from a T gondii antibody positive donor after the first four cases of primary toxoplasmosis. Ofthe seven patients not given pyrimethamine, four (57%) acquired primary Tgondii infection. This compared with two of the 14 patients (14%) given prophylaxis.

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Three patients aged 5 to 7years with aorto-left ventricular tunnel had successful surgical closure, and afourth patient aged I6 years with bad postoperative aortic regurgitation is described. The diagnosis should be considered in a child presenting with the features suggestive of severe aortic regurgitation. Early operation is recommended before the aortic annulus becomes too dilated. Clinical examinationThe three children were of normal build, and were referred to the National Heart Hospital at 5, 6, and 7 years. All were referred for surgical treatment for supposed severe aortic valve disease.Visible vigorous carotid pulses and a hyperdynamic enlarged left ventricle were constant features. The blood pressure varied from 140/50 to I50/IO mmHg. A diastolic thrill in the second and third left interspace was noted in two patients and was also evident to the right of the sternum in one and in the suprasternal notch in another. One patient had an intense systolic thrill while the others had a short murmur in systole only. All had a loud ejection sound at the apex and along the left sternal border. Aortic valve closure was always clear and the dicrotic notch was obvious on the carotid trace in all three patients (Fig. i). Pulsation to the right of the sternum was visible and palpable in all three. Chest radiographyThere was obvious dilatation of the ascending aorta in all patients, and this had been present since infancy in two (Fig. 2a, b). The left ventricle was enlarged in all, and the 7-year-old boy, who was breathless, had prominent upper lobe pulmonary veins suggesting pulmonary venous congestion. Two patients had a visible bulge in the region of the infundibulum below the main pulmonary artery shadow which was not obvious on all films but could be seen on screening to be pulsating vigorously particularly when the patient was turned into the right anterior oblique. ElectrocardiogramsAll had significant increase in left ventricular voltage such as would be expected in long-standing aortic regurgitation.

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SummaryHealth care increasingly emphasises the team approach in which doctors, nurses, and other health workers adapt and develop new skills. Before changes of this kind are widely accepted, however, there must be clarity about the training, status, authority, working relationships, career structure, and remuneration of those who undertake responsibilities well beyond their traditional roles.

In the first 11 years of the heart and heart-lung transplantation programme at Papworth Hospital, Cambridge, 356 patients underwent heart transplantation, and 73 patients received both heart and lungs. Out of 429 patients 41 (9.5 per cent) developed abdominal complications within the first 30 days, and 20 of the 41 required surgery. The complications included pancreatitis (10), peptic ulceration (8), and pseudo-obstruction (8), in addition to colonic perforation and small bowel obstruction. When laparotomy was performed it was well tolerated. This paper supports the view that successful management of abdominal complications following transplantation requires prompt diagnosis and treatment. Where doubt exists in the presence of an acute abdomen, laparotomy is the appropriate way to establish a definitive diagnosis.

T cell lymphotropic virus type III antibodies; filaria and schistosomal enzyme linked immunosorbent assay; testing of stools for ova and parasites; tests of liver function and autoantibodies; chest radiography; and abdominal ultrasound.Immunoglobulim,concentrations were normal apart fromi a slightly raised IgM.Skin biopsies on admission showed focal parakeratosis with acanthosis of the epidermis, in which numerous convoluted lymphocytes were identified. A repeat skin biopsy taken three week-s later when the skin had improved showed a perivascular lymphocytic infiltrate. Biopsy of the lymph nodes was consistent with a dermatopathic lymphadenitis.The erythroderma improved,,but the patient still required 5 mg prednisolone on alternate days and a moderately potent (group III) topical steroid cream five months after onset ofillness. Comment Toxoplasmosis in cardiac transplantationDespite new immunosuppressive regimens infections with opportunistic organisms still constitute an important threat to patients undergoing organ transplantation. Toxoplasma gondii may cause fuhninant and rapidly fatal infection in recipients of heart transplants.' We report the prevalence of infection with T gondii in recipients of heart transplants at Papworth Hospital, the role of the donated hearts as a source of infection, successful treatment of fulminant infections, and the role of pyrimethamine in prophylaxis. Patients, methods, and resultsAltogether 119 patients who had received cardiac.or cardiopulmonary transplants were.reviewed (106 men, 13 women; age range 9-54 (mean 38-6).years).Seventeen patients received conventional immunosuppression with azathioprine and steroids; cyclosporin A was used with low dose steroids in 80 patients and with azathioprine in 22. All patients received a short course of intravenous antithymocyte globulin.' Infection due to Tgondii was diagnosed if a fourfold or greater rise in the latex agglutination antibody titre was confirmed by a similar rise in dye test litrecs or the finding of cysts of T gondii in myocardial biopsy specimens, or both.2 The postoperative follow up period ranged from three to 72 months. Patients who developed infection with T gondii were treated with oral pyrimethamine 25 mg twice daily and spiramycin I g twice daily. In addition, sulphadiazine 1 g was given initially four times daily intravenously and replaced later with a mixture of three sulphonamides (Sulphatriad: sulphadiazine 185 mg, sulphamerazine 130 mg, and sulphathiazole 185 mg; May and Baker Ltd) three times daily. After the acute phase of the illness treatment continued with pyrimethamine and Sulphatriad for 10-12 months. As our initial experience showed that infection with T gondii was most likely to occur in seronegative recipients of hearts from seropositive donors we later used pyrimethamine for prophylaxis in this group.3 Pyrimethamine was administered as a single daily dose of 25 mg for six weeks postoperatively.Results in seronegative recipients ofhearts from seropositive donors (n= 14)-Early in the series seven...

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