The role of 3D speckle tracking echocardiography in the diagnosis of obstructive sleep apnea and its severity

There is a consistent relationship between obstructive sleep apnea (OSA) and cardiovascular diseases. It is already recognized that OSA may influence the geometry and function of the right ventricle (RV). This has encouraged the development of echocardiographic evaluation for screening of OSA and its severity. Three-dimensional speckle tracking echocardiography (3D STE) is in assumption better, compared with 2D STE, because it overcomes the standard 2D echo limitations. Thus, the purpose of our study is to evaluate whether 3D STE measurements, could predict the positive diagnosis and severity of OSA. We enrolled 69 patients with OSA and 37 healthy volunteers who underwent a cardiorespiratory sleep study. 2DE was performed in all patients. RVEF and 3D RVGLS were measured by 3DSTE. NT pro BNP plasma level was also assessed in all participants. 3D RV GLS (- 13.5% vs. - 22.3%, p < 0.001) and 3D RVEF (31.9% vs. 50%, p < 0.001) were reduced in patients with OSA, compared with normal individuals. 3D Strain parameters showed better correlation to standard 2D variables, than 3D RVEF. Except for NT pro BNP (p = 0.059), all parameters served to distinguish between severe and mild-moderate cases of OSA. 3D STE may be a reliable and accurate method for predicting OSA. Consequently, 3D RV GLS is a good tool of assessing the RV global function in OSA, because it correlates well with other established measurements of RV systolic function. Furthermore, 3D RV GLS was a precise parameter in identifying severe cases of OSA, while NT pro BNP showed no association.

Transthyretin cardiac amyloidosis

Transthyretin amyloid cardiomyopathy (ATTR-CM) may be an under recognized cause of heart failure (HF). TTR amyloidosis can be inherited, caused by variants in the TTR gene (ATTRv) or by deposition of wild-type TTR protein (ATTRwt), leading to high mortality if untreated. We report the case of a patient with hereditary TTR amyloidosis and mixed phenotype (both cardiac and neurological involvement). We highlight the importance of multimodal imaging in the evaluation of these patients, as early diagnosis and treatment might lead to better outcome.

The impact of continuous positive airway pressure on cardiac arrhythmias in patients with sleep apnea

Background

Obstructive sleep apnea (OSA) can lead to cardiac complications: brady and tachyarrhythmias and sudden cardiac death. Continuous positive airway pressure (CPAP) is the gold standard for the treatment of OSA. The present study aims to demonstrate the efficiency of CPAP in the treatment of cardiac arrhythmias in patients with OSA. The study also recorded the frequency of arrhythmias in patients with untreated OSA and assessed the association between the severity of OSA and the occurrence of arrhythmias.

Materials and Methods

This is a prospective cohort study. Ninety-three patients with OSA were included, aged 60 (58-64) years, with female/male sex ratio of 1:4. They were subjected simultaneously to home respiratory polygraphy examination and Holter electrocardiogram monitoring, in two different stages: at diagnosis and at the 3-month checkup after CPAP treatment. The presence of supraventricular and ventricular arrythmias was noted. Respiratory parameter values were also recorded.

Results

Statistically significant decrease in the occurrence of supraventricular (P < 0.001) and ventricular extrasystoles (P < 0.001), atrial fibrillation (AF) (P = 0.03), nonsustained ventricular tachycardia (NSVT) (P = 0.03), and sinus pauses (P < 0.001) was observed 3 months after treatment with CPAP, compared with baseline. The apnea-hypopnea index (AHI) was correlated with the ventricular extrasystoles (r = 0.273; P = 0.008). The ejection fraction of the left ventricle was inversely correlated with the episodes of NSVT (r = -0.425; P < 0.001). AF was associated with the longest apnea (r = 0.215; P = 0.04). Cardiac activity pauses were correlated with AHI (r = 0.320; P = 0.002), longest apnea (r = 0.345; P = 0.01), and oxygen desaturation index (r = 0.325; P = 0.04).

Conclusion

The prevalence of cardiac arrhythmias in patients with OSA was reduced after 3 months of CPAP therapy. Cardiac arrhythmias were correlated with the severity of OSA.

P713 An incidental finding of a completely thrombosed left ventricular pseudoaneurysm: what is the next step?

Introduction

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction. It is the result of ventricular rupture contained by the pericardial adhesions or thrombus. Although echocardiography is suitable as the initial method for diagnosis, multimodality imaging is often required in order to further characterize the pseudoaneurysm morphology and to plan the treatment.

Case report

A 56-year-old male patient with an old inferior myocardial infarction treated conservatively 6 years ago, was admitted in our department for atypical left laterothoracic pain. Three months before he had the same symptoms and an unexplained paracardiac mass was incidentally diagnosed by transthoracic echocardiography. At that time, he was evaluated by coronary angiography which showed no epicardial coronary artery stenosis. During admission, the ECG showed sinus rhythm, inferior myocardial scarring and right bundle branch block. The laboratory tests revealed cardiac enzymes within normal range, increased D-dimeri and elevated inflammatory markers. The echocardiography showed a nondilated left ventricle (LV) with preserved ejection fraction and akinesia of the inferolateral(IL) LV wall. Attached to the basal IL LV wall, an extensive mass was documented with an echogenic appearance and no color Doppler flow, suggesting a thrombosed pseudoaneurysm. A contrast enhanced computed tomography (CT) scan confirmed the diagnosis, but it was not able to establish whether the pseudoaneurysm was partially or completely thrombosed. For a more accurate morphologic and tissue characterization, a cardiac magnetic resonance imaging(CMR) was subsequently performed, that confirmed the presence of a completely thrombosed pseudoaneurysm, measuring 82x38mm. In this case, a conservative approach was initially suggested by the completely thrombosed chronic pseudoaneurysm (older than 3months and with no Doppler color flow). However, according to the literature a surgical approach should be considered when the pseudoaneurysm dimension is larger than 3 cm. Since the patient refused the surgical intervention, medical treatment was initiated with anticoagulants due to the high embolic risk, betablockers and angiotensin-receptor antagonists to maintain the blood pressure less than 120/80mmHg. At 1 month, his condition was stable. He will be reevaluated in 3 months, to monitor the possible pseudoaneurysm expansion. According to our knowledge, this is the first case of a completely thrombosed pseudoaneurysm described in the literature. Its echocardiographic, CT and CMR appearance is important for the differential diagnosis of all paracardiac masses (tumors, hiatus hernias, etc).

Conclusion

Completely thrombosed left ventricle pseudoaneurysm remains a challenging diagnosis since its echocardiographic appearance is atypical. Cardiac magnetic resonance imaging has a higher diagnostic yield and can provide important information that may influence the course of treatment.

Abstract P713 Figure. LV Pseudoaneurysm-multimodality imaging

P723 A dissecting thoracic aortic aneurysm presenting with mild symptoms in a young woman

Introduction

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat.

Case presentation

We present the case of a 29 years old young woman, brought to the emergency department with mild chest and back pain, shortness of breath on exertion with an onset of 12 days prior to admission. The patient has a history of 3 pregnancies delivered by natural birth and C-section (last one 2 years ago), but no personal cardiovascular disease history. She relates a family history of sudden cardiac death at a young age (mother, grandmother, great-grandmother) and a sister with diagnosed aortic aneurysm associated with a genetic mutation. Physical examination revealed a marfanoid habitus, diastolic heart murmur, low diastolic blood pressure (BP of 90/25 mmHg). Transthoracic echocardiography performed in the ED, discovered an anuloaortic aneurysm with a maximum diameter of 8.7 cm at the aortic root and a dissecting intimal flap of the ascending aorta up to the aortic arch. We also detected a dilated left ventricle with a low ejection fraction (30%) and a severe aortic regurgitation. The findings were confirmed by contrast-enhanced CT Angiography, showing the aneurysm of 8.4/8.7 cm and the intimal dissection flap with patency of both true- and false lumens. At this point we diagnosed an anuloaortic aneurysm with Stanford type A acute aortic dissection and a Marfan syndrome (according to the Ghent Nosology criteria). She immediately underwent surgery, the Bentall procedure was performed, consisting of a composite graft replacement of the entire ascending aorta and aortic valve, followed by direct implantation of the coronary arteries. Histopathological examination of the excised aortic wall reinforced the diagnoses of a connective tissue disorder. The early postoperative evolution was marked by the development of a left-sided hemiparesis and seizures, caused by an acute ischemic stroke. The patient was discharged after the complete resolution of the neurological symptoms under appropriate medication. Recommendations were made for periodic follow-up, genetic testing and the screening of her children after the age of 10 years old.

Conclusion

Discussions evolve around the interesting fact that she managed to survive 3 pregnancies, natural births and a C-section, without developing an aortic dissection or even a possible fatal rupture up until this presentation. It is imperative to mention that the lack of a follow-up from a general practitioner, who could have notice the signs of a possible connective tissue disorder, have possibly led to the development of such aortic sizes. The current guidelines sustain the importance of surgical approach in all types of ascending aortic dissection, the only treatment proven to increase the short- and long term mortality.

Abstract P723 Figure. Imaging studies

P1453 Unfortunate association between obstructive hypertrophic cardiomyopathy and infective endocarditis

Bacterial endocarditis is an uncommon, but potentially severe complication of hypertrophic cardiomyopathy (prevalence &lt; 1%).

We report the case of a 27-year-old woman, with low socioeconomic status, with hypertrophic cardiomyopathy, presenting with chest pain, dyspnoea at moderate effort, fever and chills. The transthoracic and transoesophageal echocardiography showed obstructive septal hypertrophic cardiomyopathy (interventricular septum of 38 mm, systolic anterior motion of the mitral valve, maximum gradient in the left ventricular outflow tract of 80 mmHg), vegetations of 10 mm, on the atrial and ventricular mitral leaflets sides, mitral valvular abcess, severe mitral regurgitation, flail of the noncoronarian aortic cusp (with a 10 mm vegetation), severe aortic regurgitation, basal SIV vegetation, pericardial effusion. The blood cultures were positive for Streptococcus mitis. The thoracic, abdominal, pelvin CT scan confirmed the diagnosis of mitral-aortic infective endocarditis , revealing also an abcess of the aortic root and multiple embolisations (spleen and right external iliac artery). The cranial CT scan was normal. At the evaluation of the foci sites, multiple dental foci were discovered and treated by multiple extractions. The endocarditis team recommended antibiotic treatment (with ampicillin), urgent bivalvular replacement (aortic and mitral valve) and septal myectomy. The surgical procedure was denied by the patient, which was after that voluntarily discharged from the hospital. The patient died from cardiac arrest (asystole) 11 days after the initial diagnosis.

A severe association between obstructive hypertrophic cardiomyopathy and infective endocarditis with multiple complications can have an initial paucisymptomatic clinical presentation.

The low socioeconomic status of the patient was correlated with inadequate oral hygiene, that was a negative prognostic factor in the outcome of the patient. It is possible that the integration of oral health in our national general health programs for people with low socioeconomic status, will decrease morbidity and improve the quality of life.

Abstract P1453 Figure. picture clinical case

Pressure dependence of the metal-insulator transition in κ-(BEDT-TTF)2Hg(SCN)2Cl: optical and transport studies

The two-dimensional organic conductor κ-(BEDT-TTF)₂-Hg(SCN)₂Cl exhibits a pronounced metal-insulator transition at [Formula: see text] K. From the splitting of the molecular vibrations, the phase transition can be unambiguously assigned to charge-ordering with [Formula: see text]. We have investigated the pressure evolution of this behavior by temperature-dependent electrical transport measurements and optical investigations applying hydrostatic pressure up to 12 kbar. The data reveal a mean-field like down-shift of [Formula: see text] with a critical pressure of [Formula: see text] kbar and a metallic state above the suppression of the charge-ordered state; no traces of superconductivity could be identified down to T  =  1.5 K. As the charge order [Formula: see text] sets in abruptly with decreasing temperature, its size remains unaffected by pressure. However, the fraction of charge imbalanced molecules decreases until it is completely absent above 1.6 kbar.

The genetics of an early Neolithic pastoralist from the Zagros, Iran

The agricultural transition profoundly changed human societies. We sequenced and analysed the first genome (1.39x) of an early Neolithic woman from Ganj Dareh, in the Zagros Mountains of Iran, a site with early evidence for an economy based on goat herding, ca. 10,000 BP. We show that Western Iran was inhabited by a population genetically most similar to hunter-gatherers from the Caucasus, but distinct from the Neolithic Anatolian people who later brought food production into Europe. The inhabitants of Ganj Dareh made little direct genetic contribution to modern European populations, suggesting those of the Central Zagros were somewhat isolated from other populations of the Fertile Crescent. Runs of homozygosity are of a similar length to those from Neolithic farmers, and shorter than those of Caucasus and Western Hunter-Gatherers, suggesting that the inhabitants of Ganj Dareh did not undergo the large population bottleneck suffered by their northern neighbours. While some degree of cultural diffusion between Anatolia, Western Iran and other neighbouring regions is possible, the genetic dissimilarity between early Anatolian farmers and the inhabitants of Ganj Dareh supports a model in which Neolithic societies in these areas were distinct.

The value of transthoracic and transesophageal echocardiography for the diagnosis of the native aortic infective endocarditis valve complications: a case report and literature review

Despite its current limitations transthoracic echocardiography is still widely used for the anatomical and functional evaluation of patients with infective endocarditis. However, all these limitations can be overcome by using transesophageal echocardiography. We present the case of a 42-year-old male patient, diagnosed with aortic valve infective endocarditis, whose transthoracic echocardiography showed only a cusp vegetation and aortic regurgitation, but raised the suspicion of periannular complications. The transesophageal echocardiography revealed a circular aortic root abscess and a ventricular septal defect with left-to-right shunt, and consequently leads to a complete different surgical tactical approach. The patient was urgently referred for surgery due to the rapid deterioration of the hemodynamic status, and had a good outcome on the short-term follow-up.

Piston pressure cell for low-temperature infrared investigations

The design of a piston pressure cell ranging up to approximately 11 kilobars is reported, which allows for optical reflection measurements in the infrared spectral range from 100 to 8000 cm(-1) down to temperatures as low as 6 K. The mechanical alignment and vacuum considerations are discussed before details of the sample preparation are given, with particular emphasis on small and fragile single crystals, mosaics, and pressed powder. A few examples of one- and two-dimensional organic conductors illustrate the performance.

Drainage of cerebral abscesses prior to valve replacement in stable patients with acute left-sided infective endocarditis

Despite the medical and surgical advancements in the treatment of patients with acute infective endocarditis (IE), neurologic complications remain problematic. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are characteristic to left-sided pathology of native or prosthetic valves. We present a case of a 46 year old male patient who presented to our clinic with mitral valve IE caused by coagulase negative staphylococcus. Although under correct antibiotic treatment, he continued to be feverish and started to present unspecific neurological symptoms (amnesia, confusion, asthenia and general malaise). The cerebral magnetic resonance imaging (MRI) revealed multiple cerebral abscesses. Because the patient was hemodynamically stable we decided to address the cerebral abscess first and the cardiac lesion second. The patient made a full recovery after undergoing antibiotic treatment and surgical procedures of drainage of the cerebral abscess and mitral valve replacement. After reviewing the literature regarding the management of patients with IE and cerebral complications and based on this particular case, we conclude that in select cases of stable patients with cerebral abscess and IE, the neurological lesion should always be addressed first and cardiac surgery should be performed second.

Pressure-dependent relaxation in the photoexcited mott insulator ET-F2TCNQ: influence of hopping and correlations on quasiparticle recombination rates

We measure the ultrafast recombination of photoexcited quasiparticles (holon-doublon pairs) in the one dimensional Mott insulator ET-F(2)TCNQ as a function of external pressure, which is used to tune the electronic structure. At each pressure value, we first fit the static optical properties and extract the electronic bandwidth t and the intersite correlation energy V. We then measure the recombination times as a function of pressure, and we correlate them with the corresponding microscopic parameters. We find that the recombination times scale differently than for metals and semiconductors. A fit to our data based on the time-dependent extended Hubbard Hamiltonian suggests that the competition between local recombination and delocalization of the Mott-Hubbard exciton dictates the efficiency of the recombination.

Nuclear deformation and neutron excess as competing effects for dipole strength in the pygmy region

The electromagnetic dipole strength below the neutron-separation energy has been studied for the xenon isotopes with mass numbers A=124, 128, 132, and 134 in nuclear resonance fluorescence experiments using the γELBE bremsstrahlung facility at Helmholtz-Zentrum Dresden-Rossendorf and the HIγS facility at Triangle Universities Nuclear Laboratory Durham. The systematic study gained new information about the influence of the neutron excess as well as of nuclear deformation on the strength in the region of the pygmy dipole resonance. The results are compared with those obtained for the chain of molybdenum isotopes and with predictions of a random-phase approximation in a deformed basis. It turned out that the effect of nuclear deformation plays a minor role compared with the one caused by neutron excess. A global parametrization of the strength in terms of neutron and proton numbers allowed us to derive a formula capable of predicting the summed E1 strengths in the pygmy region for a wide mass range of nuclides.

Magnetic ordering and charge dynamics in κ-(BEDT-TTF)2Cu[N(CN)2]Cl

The Mott insulator κ-(BEDT-TTF)2Cu[N(CN)2]Cl consists of molecular dimers arranged on an anisotropic triangular lattice. At low temperatures a pronounced dielectric anomaly is observed, and eventually a canted antiferromagnetic ground state forms. Optical spectroscopy clearly rules out charge imbalance and the existence of quantum electric dipoles with a dipolar-spin coupling. Here we suggest a novel form of spin-charge coupling where the prominent in-plane dielectric response in κ-(BEDT-TTF)2Cu[N(CN)2]Cl is explained by short-range discommensurations of the antiferromagnetic phase in the temperature range 30 K < T < 50 K, and by relaxation of charged domain walls in the ferromagnetic structure at lower temperatures.

Angle-dependent evolution of the Fulde-Ferrell-Larkin-Ovchinnikov state in an organic superconductor

We report magnetic-field and angular-dependent high-resolution specific-heat measurements of the organic superconductor β''-(BEDT-TTF)2SF5CH2CF2SO3. When the magnetic field is aligned precisely within the conducting BEDT-TTF layer, at low temperatures a clear upturn of the upper critical field beyond the Pauli limit of 9.73 T is observed, hinting at the emergence of a Fulde-Ferrell-Larkin-Ovchinnikov state. This upturn disappears when the field is oriented out of plane by more than ∼0.5  deg. For smaller out-of-plane angles, the specific-heat anomaly at T(c) sharpens and a second peaky phase transition appears within the superconducting state.

Magnetic frustration in a quantum spin chain: the case of linarite PbCuSO4(OH)2

We present a combined neutron diffraction and bulk thermodynamic study of the natural mineral linarite PbCuSO4(OH)2, this way establishing the nature of the ground-state magnetic order. An incommensurate magnetic ordering with a propagation vector k=(0,0.186,1/2) was found below T(N)=2.8 K in a zero magnetic field. The analysis of the neutron diffraction data yields an elliptical helical structure, where one component (0.638μ(B)) is in the monoclinic ac plane forming an angle with the a axis of 27(2)°, while the other component (0.833μ(B)) points along the b axis. From a detailed thermodynamic study of bulk linarite in magnetic fields up to 12 T, applied along the chain direction, a very rich magnetic phase diagram is established, with multiple field-induced phases, and possibly short-range-order effects occurring in high fields. Our data establish linarite as a model compound of the frustrated one-dimensional spin chain, with ferromagnetic nearest-neighbor and antiferromagnetic next-nearest-neighbor interactions. Long-range magnetic order is brought about by interchain coupling 1 order of magnitude smaller than the intrachain coupling.

Relationship between the heparin management test and the HemoTec activated clotting time in patients undergoing percutaneous coronary intervention

Point-of-care whole blood coagulation tests are critical in the management of patients who undergo percutaneous coronary intervention. The Hemochron and HemoTec devices have been traditionally used to measure the activated clotting time (ACT) in the cardiac catheterization laboratory. The heparin management test (HMT) was recently introduced into clinical practice as an alternative method to current ACT measurements that uses a different sample volume, contact activators and detection system to measure whole blood coagulation. We compared the HMT to the HemoTec ACT in 68 prospectively enrolled patients (127 blood samples) undergoing percutaneous coronary intervention. Measurements were performed 10 minutes after the initial heparin bolus and thereafter at the discretion of the attending physician. The mean HMT was 41 seconds higher (approximately 15%) than the HemoTec ACT (HMT 304+/-59 vs. ACT 263+/-52, P< 0.0001), but there was a significant correlation between the methods (r=0.77, P<0.0001). However, there was increasing disagreement between the two methods as the level of anticoagulation increased. The relationship between HMT and ACT was similar in patients in whom glycoprotein IIb/IIIa inhibitors were used. The HMT, therefore, appears to be more sensitive to heparin anticoagulation that the HemoTec ACT and correlates well with it in the range required for percutaneous coronary intervention.

The expression of substance P and its neurokinin-1 receptor mRNA in the bovine corpus luteum of early developmental stage

Related to all leukocytes, 90% of eosinophils are recruited into the bovine corpus luteum of early developmental stage. We here describe a simultaneous appearance of substance P (SP)-positive fibre-like structures and the neurokinin-1 (NK-1) receptor mRNA for SP. Substance P was depicted by using indirect immunohistology and immunofluorescence localization. The dot blot analysis confirmed the presence of SP at the protein level. Using nested reverse transcribed-polymerase chain reaction (RT-PCR) analysis, a 358 bp long partial bovine receptor mRNA for SP (NK-1) was sequenced in the spinal cord. The mRNA for SP and for the NK-1 receptor were then detected in the corpus luteum of early developmental stage with RT-PCR and nested RT-PCR. We conclude: The production of SP and the expression of NK-1 receptor mRNA may be involved in the selective recruitment of eosinophils into the bovine corpus luteum of early developmental stage.

[The practicability, patient comfort and efficiency of the pre-oxygenation device NasOral]

OBJECTIVE

We examined the new NasOral-System (NOS; Logomed, Germany), which is designed for a fasten and more complete denitrogenization when compared to the use of a contemporary face-mask. The patient inhales oxygen via a nose mask and exhales via mouthpiece. Nose mask and mouthpiece have built-in one-way valves, resulting in an unidirectional gas flow (nasal-oral).

METHODS

With approval of the local ethic committee, pre-oxygenation with both the NOS and a face mask (Laerdal) was studied in 50 adult patients. Midazolam 3.75-7.5 mg p.os was given for premedication. The NOS was studied in two different ways: the nose mask fastened by rubberband and with the nose mask held by hand. Prior to induction every patient received every system in a randomised manner. Semi-closed-anaesthetic circle-systems with a fresh-gas-flow of 10 litres/min were used. The FEO2 over 5 min of pre-oxygenation were recorded (AS-3, Datex). Speed and degree of the denitrogenization was documented by an external digital data-acquisition system. Practicability of the systems regarding the anaesthesists (n = 27) and patient comfort were evaluated by means of a standardized postoperative questionnaire.

RESULTS

The hand-held NOS is definitely more effective and reliable than both the NOS fastened by rubber-band and the classical face mask: 80% of the hand-held NOS were able to achieve a FEO2 of > or = 0.8 compared to only 36% of the NOS fixed by rubber-band, face mask: 48%. FEO2 of > or = 0.8 was achieved with 52% of the hand-held NOS in 90 s, a time we consider practical for daily routine, whereas only 10% of the NOS fixed by rubberband and 14% of the face masks accomplished this threshold. A cooperative patient is an important condition when using the NOS: a strong premedication effect, absence of dentures, and patients who can not inspire via nose and expire via mouth involve impairment of the positive effects of the NOS. 21% of the anaesthesists felt disturbed by the NOS. 72% do not believe, that induction of anaesthesia will become more safe with the NOS. For 8 patients, breathing with the NOS was disagreeable (face-mask: 3 patients), 15 were disturbed by the nose part/mouth piece (face-mask: no patient).

CONCLUSION

An acceptable FEO2 of > or = 0.8 can be achieved only without leakage of both the NOS and the face-mask. Therefore, routine FEO2-monitoring seems highly desirable. Efficiency of the hand-held NOS is much better than with the NOS fastened by rubberband or the face mask. However, even the hand-held NOS cannot guarantee for optimal denitrogenization. Practicability in daily use was poor, because a test of airway patency by manual ventilation prior to relaxation/intubation is not possible with the NOS. Using the device as a help in apnoic oxygenation seems useful.

Prenatal diagnosis of a partial trisomy 19q

Phenotypic anomalies due to a genetic imbalance of chromosome 19 have been reported in very rare postnatal cases. Here a case of partial trisomy 19 diagnosed prenatally by ultrasonography and cytogenetic analysis is presented. Detailed evaluation by sonography showed major anomalies which could be correlated to the typical appearance of this chromosomal anomaly. Termination of pregnancy at 21 weeks of gestation was performed, and the prenatal diagnosis was confirmed postnatally by autopsy. The syndrome in this case was caused by a duplication of the long arm of chromosome 19 (46,XY, dup(19) (q13.1-->qter).

A convenient assay for estimating the possible involvement of efflux of fluoroquinolones by Streptococcus pneumoniae and Staphylococcus aureus: evidence for diminished moxifloxacin, sparfloxacin, and trovafloxacin efflux

We developed a simplified assay for estimating efflux by measuring the effect of reserpine on the growth of Streptococcus pneumoniae and Staphylococcus aureus over 7 h. Reserpine enhanced ciprofloxacin and levofloxacin 17 to 68%. The hydrophobic drug trovafloxacin and the drug moxifloxacin, with a bulky C-7 substituent but hydrophilicity similar to that of levofloxacin, showed little (0 to 11%) reserpine-enhancing effect. The ease of resistant mutant strain selection correlated with efflux susceptibility.

Contribution of topoisomerase IV and DNA gyrase mutations in Streptococcus pneumoniae to resistance to novel fluoroquinolones

In this study, we assessed the activity of ciprofloxacin, levofloxacin, sparfloxacin, and trovafloxacin against clinical isolates of Streptococcus pneumoniae that were resistant to the less-recently developed fluoroquinolones by using defined amino acid substitutions in DNA gyrase and topoisomerase IV. The molecular basis for resistance was assessed by using mutants selected with trovafloxacin, ciprofloxacin, and levofloxacin in vitro. This demonstrated that the primary target of trovafloxacin in S. pneumoniae is the ParC subunit of DNA topoisomerase IV, similar to most other fluoroquinolones. However, first-step mutants bearing the Ser79-->Phe/Tyr substitution in topoisomerase IV subunit ParC were susceptible to trovafloxacin with a minimum inhibitory concentration of 0.25 microg/ml, and mutations in the structural genes for both topoisomerase IV subunit ParC (parC) and the DNA gyrase subunit (gyrA) were required to achieve levels of resistance above the breakpoint. The data also suggest that enhanced activity of trovafloxacin against pneumococci is due to a combination of factors that may include reduced efflux of this agent and an enhanced activity against both DNA gyrase and topoisomerase IV.

[Coronary emergency--the best pathway for rapid diagnosis]

Acute coronary syndrome includes instable angina pectoris, non-Q-wave infarction and, in current publications, usually also Q-wave infarction. The common pathological substrate is intracoronary plaque rupture with the formation of a thrombus. A careful work-up of the symptoms and their classification permits a presumptive diagnosis. This must then be confirmed by ECG without delay. On the basis of the clinical picture and the ECG, an acute myocardial infarction can be diagnosed unequivocally, and treatment initiated immediately. In these cases, laboratory findings merely confirm the diagnosis, and provide information on the size of the infarction and the success of reperfusion. In the event of an unclear ECG, rapid troponin tests may help to establish the diagnosis and monitoring of treatment, as well as providing prognostic information. While, formerly, a strict differentiation was made between instable angina pectoris, non-transmural and transmural infarctions, current pathophysiological knowledge makes the overarching term of acute coronary syndrome appear to be a more suitable term.

Use of modified fluid gelatin and hydroxyethyl starch for colloidal volume replacement in major orthopaedic surgery

We have compared 6% hydroxyethyl starch (HES 200/0.5) with 3% modified fluid gelatin (MFG) for volume replacement in major orthopaedic surgery and studied the effects on haemodynamic state, colloid osmotic pressure, blood clotting and plasma homeostasis. Using a controlled, randomized, single-blind clinical design, we studied 46 consecutive patients undergoing major elective orthopaedic hip surgery. The two groups were comparable in age, body weight and duration of surgery. Patients were maintained haemodynamically stable using both HES and MFG over the entire study. Fluid balance and colloidal replacement volumes were comparable in both groups (median perioperative infusion volume: HES 2500 ml, MFG 2400 ml). Laboratory variables were not clinically different. We conclude that both colloidal solutions were comparable in volume efficacy and effects on plasma oncotic pressure, clotting and plasma homeostasis. In the small number of patients studied, 6% HES 200/0.5 was found to be safe when administered in amounts corresponding to the currently accepted maximum daily dose in Germany and France of 33 ml/kg body weight and 2.0 g/kg body weight, respectively.

Growth and pubertal development in patients with meningomyelocele: a retrospective analysis

Our retrospective analysis of growth and pubertal development includes 109 children and adults with meningomyelocele (MMC) (52 M, 57 F) aged 3.2-21.0 years (median 8.9 years). Anthropometric data, growth-retarding factors and data on pubertal development were analysed in comparison to the normal population using standards from Prader et al. (1). The results (mean +/- SD) were as follows. Fifty patients (46.8%) had short stature (height SDS for chronological age (SDS CA) < -2). The supine length was influenced by the level of the lesion (height SDS CA: > or = L2 -3.13 +/- 1.62, < or = S2 -0.46 +/- 1.27), ambulatory status, skeletal deformities and pubertal stage. The mean adult height (n = 15, age 16.1-21.0 years) measured 141.3 cm for women (height SDS CA -3.83 +/- 1.79) and 159.2 cm for men (height SDS CA -2.27 +/- 1.81). In 82.6% of the subjects (n = 90), arm spans were within the normal range. Reduced arm spans (SDS < -2) as found in 19 patients (17.4%) with short stature (mean height SDS CA -3.29 +/- 1.29) may be caused by factors other than neurological lesions and skeletal deformities, and require further endocrinological studies. Out of 27 pubertal patients, central precocious puberty was diagnosed in five girls. The stages of puberty in MMC girls developed earlier than expected for the age-related group.

[Dwarfism in pericentric inversion of the X-chromosome]

We report on a 9 2/12 year old girl with pericentric inversion of the X-chromosome. It was diagnosed accidentally by a chromosome-analysis led through because of small stature. She bears a strong phenotypic resemblance to her mother (normal chromosomes), carrier of the pericentric inversion however is the phenotypically normal father. The breakpoint of the X-chromosome not lying within the critical region suggests that the patient will neither suffer a gonadal dysfunction. Both short stature and phenotypic dysmorphic features have familial cause.

[Roentgen findings in spontaneous esophageal perforation (Boerhaave syndrome)]

Having experienced two cases of Boerhaave's syndrome (spontaneous rupture of the oesophagus), one a 42-year-old man, the other a 76-year-old woman, who both died of complications failing operative repair, the authors undertook a survey of the literature in order to evaluate the role of radiology in the detection of this life-threatening condition. An analysis of 118 clinically and 67 radiologically well-documented cases yielded pathologic findings in chest X-rays in 90% of the cases. Hydropneumothorax was found in 51%, pneumomediastinum in 30%, isolated pleural effusion in 25%, and infiltration of the parenchyma in 14% of the patients. In all cases it was possible to demonstrate by contrast medium-filling of the oesophagus with an aqueous medium.