[Takayasu arteritis--a rare differential diagnosis in aortic dissection. A case report]

A 36-year-old woman was delivered to our hospital with suspected aortic dissection from an outlying hospital in May 1994. She reported a history of acute and persistent thoracic and epigastric pain. The physical examination revealed a minor senso-motorical palsy of the left side as residuum after minor strokes occurring 12/93 and 4/94. Also, a marked hypertension (170/100 mm Hg) was present. The hematologic and blood chemical values were normal with a white cell count of 12,000, an erythrocyte sedimentation rate (ESR) of 19 mm/h and a c-reactive protein (CRP) of 2.2 mg/dl. The electrocardiogram was normal. Transthoracic- and transesophageal-echocardiography (TTE, TEE) revealed an eccentric thickening of the whole wall of the descending aorta up to the bifurcation with a stenosis at the side of the diaphragma. Those findings were confirmed by computed tomography. Because of the acute onset of symptoms and the results of the imaging procedures aortic dissection de Bakey type III was diagnosed and the patient was treated with beta-blockers. Symptoms were relieved over the following days. After 2 days a pleuric effusion developed and all inflammatory tests rose (fibrinogen 780 mg/dl, ESR 80 mm/hr, CRP 16 mg/dl). At this time the differential diagnosis of an arteritis was considered. A new TEE-study demonstrated no change, but now more attention was given to the fact that no dissection membrane could be visualized and all wall structures were thickened. In combination with the history of cerebral infarction due to carotid obstruction and the elevated laboratory values the diagnosis of Takayasu-aortitis was established and corticoid therapy was started. Within a few weeks the arterial changes diminshed markedly and the woman became free of symptoms. This case demonstrates the rare situation of an arteritis mimicking aortic dissection, in which the clinical course revealed the true diagnosis.

Tropheryma whippelii endocarditis confirmed by polymerase chain reaction

This report concerns a patient with cardiac manifestation of Whipple's disease. For the first time, the gene that encodes the 16s rRNA of Tropheryma whippelii was identified in a native aortic valve by means of a polymerase chain reaction technique. DNA amplification gives evidence of Tropheryma whippelii as a causative organism in infective endocarditis.

Beating neonatal rat cardiomyocytes as a model to study the role of xenoreactive natural antibodies in xenotransplantation

The hyperacute rejection reaction of xenogeneic organs is supposed to be triggered by xenoreactive natural antibodies of the recipient organism. In an experimental set-up allowing for rapid medium exchange, primary cultures of spontaneously beating neonatal rat cardiomyocytes were challenged with dialyzed human serum containing xenoreactive natural antibodies. After adding the serum specimens, a reproducible pattern of disturbed contractility was observed: following an initial increase in beating frequency, spontaneous contractions stopped completely. This standstill was reversible in all experiments. No signs of permanent cytotoxicity were observed. The temporary cessation of contractions was prevented by raising extracellular calcium concentration, but not by extracellular electrical stimulation. After absorption of xenoreactive natural antibodies, cellular contractions ensued without interruption. Inactivated serum specimens produced similar effects on contractility, although the duration of the standstill period was significantly shorter. The same qualitative phenomenon occurred when sera of other xenogeneic species were used. These results point to a temporary functional disturbance of parenchymal cells by xenoreactive natural antibodies, whereas no chronic cytotoxicity was conspicuous in these experiments.

Stability of vitamins in soybean oil fat emulsion under conditions simulating intravenous feeding of neonates and children

The stability of the fat-soluble vitamins and thiamine, riboflavin, pyridoxine, ascorbate, and folic acid when administered as part of Intralipid 10% was evaluated. Intravenous pediatric vitamin formulations (Vitalipid N Infant and Soluvit Infant) containing the daily dose for term neonates were diluted with Intralipid to final volumes of 12.5 mL or 260 mL. The volumes were then delivered for 24 hours via dihexylethyl-phthalate-free in vitro infusion systems that simulated clinical conditions. The first vitamin-Intralipid admixture (12.5-mL volumes) was pumped (by syringe) during 24 hours through neonatal infusion sets placed in an incubator (37 +/- 1 degree C, bilirubin light). Aliquots were collected at the beginning of the experiment and after 24 hours of infusion. The second admixture (260-mL volumes) was pumped (by a peristaltic pump) through infusion sets during 24 hours and was exposed to periodic indirect sunlight and to continuous fluorescent light to stimulate the feeding of a child. Aliquots were collected at 0, 8, and 24 hours during administration of the admixtures. The vitamin concentrations were measured by high-performance liquid chromatography. The effect of the vitamins on the stability of the emulsion was also assessed by visual inspection, lipid globule size distribution, and pH change. Losses of vitamins vary from different experimental conditions and were for the fat-soluble vitamins essentially nil, except for phylloquinone, which was 5% to 17% below the initial level. Thiamine, pyridoxine, and folic acid were stable. Losses of riboflavin and ascorbate amounted to 10% to 20% and 9% to 52%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of three different preparation techniques on the results of human sperm morphology analysis

Using 158 unselected semen samples the present study has analysed how the results of sperm morphology assessment were influenced by different techniques for preparing the slides for microscopic assessment. All three techniques compared, the Papanicolaou stain (PAP), the Shorr stain (SHO) and the 'wet preparations' protocol (WET) are currently recommended by the World Health Organization for use in andrology laboratories. Mean percentages of morphologically normal spermatozoa were identical on PAP and SHO slides (31.1%), but were significantly lower in wet preparations (12.3%). Wide divergence of results obtained with the three different methods was also found with respect to the percentage of sperm with head, midpiece and tail defects and two 'indices of teratozoospermia'. For the majority of parameters assessed, linear regression analysis revealed a poor correlation between evaluations of PAP, SHO and WET slides (r values ranging from 0.01 to 0.87). We conclude that only one standard method should be recommended for the preparation of morphology slides in order to ensure inter-laboratory comparability of results and to enhance the value of sperm morphology analysis for predicting fertility.

Controversial aspects of coronary endarterectomy

Between 1980 and 1987, 635 patients underwent coronary bypass grafting combined with coronary endarterectomy. A total of 728 vessels were endarterectomized and grafted. There were 15 early deaths (2.3%). The mortality rate was higher (7.8%) for multiple-vessel endarterectomy (p less than 0.05). The ratio of MB fraction of creatine kinase to total creatine kinase was greater than or equal to 0.10 in 48% of the cases. The first consecutive 132 survivors were followed for an average of 16 months (range, 4 months to 5 years). No late deaths occurred. Fifty-nine unselected patients underwent postoperative recatheterization at a mean interval of 18 months. An improvement in heart wall contractility could be detected in 13 patients (16.5%) and deterioration in 14 patients (17.7%). A more detailed analysis of wall contractility showed a higher rate of improvement in the posterior wall than in the anterior wall (p greater than 0.05). Furthermore, the better the contractility before operation, the greater the rate of deterioration after operation (p less than 0.05). Despite an average of 55% of all endarterectomized vessels being occluded or severely restenosed, 90% of the patients were clinically improved. A multiparametric analysis revealed that the revascularization of myocardial areas that required endarterectomy had no significant influence with respect to clinical improvement. Endarterectomy should be limited, whenever possible, to myocardial areas with already impaired contractility. Endarterectomy of multiple branches should be treated with caution because the risk of deterioration is potentiated, with a significantly higher perioperative mortality rate.

Long-term follow-up after Carpentier tricuspid valvuloplasty

To study the long-term results of tricuspid valvuloplasty, pre- and postoperative (51 +/- 17 months) echocardiographic and catheterization data were collected from 51 patients (aged 59 +/- 9 years). Because of severe mitral stenosis all patients received a heterograft in the mitral position and underwent reconstructive tricuspid surgery with Carpentier rings. With regard to postoperative clinical outcome three patient groups were distinguished: 37 patients (group A) showed clear clinical improvement; in seven patients mild, and in three patients moderate tricuspid regurgitation persisted. A mild tricuspid stenosis of less than 4 mm Hg mean diastolic gradient was found in 11 patients. Patients in group B (n = 8) showed no clinical improvement, but there was persistence of moderate tricuspid regurgitation associated with nearly unchanged pulmonary hypertension in five patients and moderate tricuspid stenosis in two. Six patients (group C) showed deterioration of their clinical status; in two patients a severe degree of tricuspid regurgitation persisted, and four patients were first seen with a tricuspid stenosis with a mean diastolic gradient greater than 7 mm Hg. Analysis of postoperative data showed that tricuspid stenosis may develop during surgery in patients with slightly shrunken valve leaflets. Although the area of the anterior tricuspid leaflet was slightly underestimated, we found that long-term results of tricuspid valve annuloplasty with a Carpentier ring were encouraging. Doppler echocardiography for detection of tricuspid regurgitation and transvalvular pressure gradient showed results identical to hemodynamic data and is a suitable and sensitive method for evaluating postoperative results after tricuspid valve annuloplasty.

[Motion analysis of the Carpentier ring in the tricuspid position: an echocardiographic and hemodynamic study]

The echocardiographic and hemodynamic results before and after (30 +/- 4 months) mitral valve replacement and tricuspid valvuloplasty using a Carpentier ring were compared in 37 patients. The motion of the Carpentier ring in the echocardiogram was related to the pulmonary artery pressure curve and the intracardiac phonocardiogram for exact temporal relation. Pressure measurements were done using a tip micromanometer. Postoperatively 29 patients were clinically improved showing a decrease of the mean pulmonary artery pressure from 63 +/- 14 mm Hg to 41 +/- 18 mm Hg (p less than 0.001) as well as of the right atrial pressure from 13 +/- 4 mm Hg to 8 +/- 3 mm Hg (p less than 0.01). The postoperative decrease of the opening amplitude of the septal tricuspid leaflet from 22 +/- 3 mm to 10 +/- 4 mm (p less than 0.001) and of the EF-slope from 125 +/- 45 mm/s to 34 +/- 41 mm/s (p less than 0.001) in 9 patients was a sign of an inflow obstruction in the right ventricle. During the synchronous pressure measurement in the right ventricle and in the right atrium, a mean diastolic pressure gradient of 3.9 +/- 1.4 mm Hg was registered postoperatively in these patients. Five patients showed persisting right heart failure, in one a severe tricuspid regurgitation was still present, in 4 patients the pressure gradient exceeded 5 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic and hemodynamic evaluation of carpentier tricuspid valvuloplasty

To study the long-term results of tricuspid valvuloplasty, pre- and postoperatively (39 +/- 11 months), echocardiographic and catheterization data were collected in 37 patients (mean age, 58 +/- 8 years). Because of severe mitral stenosis, all patients received a porcine heterograft in the mitral position and underwent reconstructive tricuspid surgery with Carpentier rings (#32, n = 12; #34, n = 15; #36, n = 10). Sizing was performed by measuring the anterior leaflet area using an obturator. In nine patients, tricuspid leaflets were slightly shrunken at the insertion site of the chordae tendineae. Postoperative echocardiography and right heart catheterization were performed with simultaneous pressure recordings in the right ventricle and right atrium. A significant clinical improvement was noted in 24 patients, and this correlated with significant hemodynamic improvement. In eight patients, no clinical improvement was observed. Patients were divided into subgroups according to echocardiographic and hemodynamic criteria. Group A (n = 17) was composed of patients with significant improvement of hemodynamics, without detectable tricuspid valve dysfunction. Group B (n = 11) was composed of patients with slight-to-moderate tricuspid incompetence, detected by contrast echocardiography. In nine of these patients, the size of the RA and the diameter of the IVC were significantly smaller than preoperatively. In patients of Group C, echocardiography and catheterization data showed a slight-to-moderate tricuspid stenosis with a mean diastolic pressure gradient of 3.9 +/- 1.4 mm Hg (max 6.2 mm Hg, min 2.4 mm Hg). Although the area of the anterior tricuspid leaflet was slightly underestimated, we determined that long-term results of tricuspid valve annuloplasty with a Carpentier ring were encouraging.

[Tumors of the colon following ureterosigmoidostomy]

This report presents three cases of colon tumors which developed after an ureterosigmoidostomy. In a checkup, four years after the operation, an inflamed polyp was found in one patient. The second patient developed an adenoma in the section of the colon where the ureter had been implanted. The last patient died of adenocarcinoma of the colon 26 years after her operation. Possible reasons for the development of the tumors, specifically the cancerous ones, are discussed. The risk of developing colon carcinoma is 500 times higher in those who have had an ureterosigmoidostomy than in healthy people. In the case that the ureters are rediverted the section of the colon where they were previously attached must be excised; since there is a strong possibility of cancerous development. To detect the early development of tumors in the colon, we suggest that patients have their stool tested for blood at regular intervals starting 3 years post operatively. If no problems arise barium enema and coloscopy are recommended every five years.