Artificial Intelligence and Transcatheter Interventions for Structural Heart Disease: A glance at the (near) future

With innovations in therapeutic technologies and changes in population demographics, transcatheter interventions for structural heart disease have become the preferred treatment and will keep growing. Yet, a thorough clinical selection and efficient pathway from diagnosis to treatment and follow-up are mandatory. In this review we reflect on how artificial intelligence may help to improve patient selection, pre-procedural planning, procedure execution and follow-up so to establish efficient and high quality health care in an increasing number of patients.

Incremental value of cardiovascular magnetic resonance imaging in family screening for hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Genetic testing in relatives of hypertrophic cardiomyopathy (HCM) patients can lead to early identification of carriers of pathogenic DNA variants (G+), before onset of left ventricular hypertrophy (LVH). Repeated evaluation by electrocardiography (ECG) and transthoracic echocardiography (TTE) is recommended to detect HCM during follow-up. Cardiovascular magnetic resonance (CMR) imaging has become valuable in the work-up of HCM, although its role in G+ subjects has not been extensively evaluated. In this study, we investigated the value of CMR in the G+/LVH- population.

We included 55 G+ subjects who underwent CMR in addition to ECG and TTE, with a maximal wall thickness (MWT) <15mm on TTE. The CMR imaging protocol consisted at least of steady state free procession imaging and 2-dimensional late gadolinium enhancement (LGE) images. ECGs were considered abnormal in case of pathologic Q waves, T wave inversion or signs of LVH (by voltage criteria including Sokolow-Lyon and a Romhilt-Estes score ≥4). TTEs were abnormal in case of LVH (defined as MWT≥10mm). For both modalities, the diagnosis of HCM was based on a MWT≥13mm. The yield of CMR relative to ECG/TTE was assessed by comparing the proportion of HCM diagnoses and the presence of other phenotypic features. Forward step logistic regression was used to assess whether the presence of TTE/ECG abnormalities could predict reclassifications or abnormalities (crypts and LGE) on CMR.

An overview of ECG/TTE and CMR findings is shown in the Figure. Two of 16 (13%) subjects diagnosed with HCM on TTE were reclassified as having no HCM on CMR, and 8 of 39 (21%) subjects without HCM on TTE were reclassified as HCM on CMR. These 8 subjects had a mean MWT of 15.4 ± 2.6 mm on CMR and a mean MWT difference of 4.5 ± 2.9 mm (range 1.7-9.4) compared to TTE, which in 3 cases was explained by a hook-shaped thickening of the basal anterior wall in the 2 chamber view, not visible on TTE. Compared to subjects without HCM on both modalities, the reclassified group had a significantly higher QRS duration (104 ± 14 vs 93 ± 11 ms, p = 0.03) and anterior mitral valve leaflet length (30 ± 4 vs 26 ± 3 mm, p = 0.01). Of the 13 subjects with normal ECG/TTE results, none were reclassified as HCM using CMR.

The proportion of additional CMR abnormalities was large in subjects with and without abnormal ECG/TTE results (57% vs 38%, p = 0.24). Subjects with poor TTE image quality were equally likely to be reclassified compared to those with sufficient image quality (10% vs 24%, p = 0.19). Logistic regression demonstrated that the presence of TTE/ECG abnormalities (odds ratio [OR] 8.7 [1.3-59.0], p = 0.03) and age (OR 1.1 [1.0-1.2], p < 0.01) independently predicted reclassifications or presence of abnormalities using CMR.

Additional CMR imaging reclassifies 18% of subjects. Subjects with normal ECG and TTE results are not diagnosed as HCM on CMR, but the prevalence of HCM-related abnormalities on CMR was high in subjects with and without ECG/TTE abnormalities.

Abstract Figure. Diagnostic approach and CMR findings

Differences in left ventricular mass and morphology and right ventricular function differentiate phenotype-negative sarcomere gene mutation carriers from healthy volunteers

Funding Acknowledgements

Type of funding sources: None.

Carriers of pathogenic DNA variants (G+) causing hypertrophic cardiomyopathy (HCM) can be identified by genetic testing, before manifestation of left ventricular hypertrophy (LVH). These G+/LVH- subjects are routinely monitored for phenotypic expression, which, alongside LVH, can include other HCM-related abnormalities, including crypts and myocardial fibrosis. Cardiovascular magnetic resonance (CMR) imaging has emerged as a valuable technique in diagnosing and follow-up of HCM. In this study, we identified clinical features of subclinical HCM in a G+/LVH- population compared to healthy subjects.

We studied 33 G+ subjects with CMR and a maximal wall thickness (MWT) <13mm, and compared them to an age- and gender-matched group of 35 healthy controls  (44 ± 14 vs 48 ± 10 y, p = 0.17; 11 (33%) vs 12 (34%) men, p = 0.93). The CMR imaging protocol consisted of 1) steady state free procession cine imaging, 2) 2-dimensional late gadolinium enhancement (LGE) images in the G+ patients and 3) pre-contrast T1 mapping using a modified look-locker inverse recovery sequence. We assessed CMR examinations for features of HCM. Forward logistic regression analysis was performed to determine which of the CMR characteristics were predictive of G+ status.

G+ subjects had a higher MWT (10.9 ± 1.6 vs 10.2 ± 1.3 mm, p = 0.04), a similar interventricular septal wall (IVS) thickness (8.8 ± 1.6 vs 8.7 ± 1.6 mm, p = 0.85), a smaller posterior wall (PW) and a higher IVS/PW ratio (6.6 ± 1.2 vs 7.7 ± 1.3mm, p < 0.001; 1.4 ± 0.3 vs 1.1 ± 0.2, p = 0.001). Indexed left ventricular (LV) mass was significantly lower in the G+ group (Table). LV function was similar (63 ± 6 vs. 61 ± 5%, p = 0.12), but right ventricular (RV) function was higher in the G+ group. They often had a characteristic hook-shaped thickening of the basal anterior wall (7 (21%) vs 0, p < 0.004; Figure) and  more frequently exhibited myocardial crypts. Midwall LGE was present in 3 (9%) G+ subjects. Native septal T1 values were elevated in G+ patients compared to controls, although mostly within the normal range (986 ± 31 vs 963 ± 28 ms, p < 0.01). Crypts, indexed LV mass and RV ejection fraction were significant predictors of G+ status in logistic regression analysis (Table).

CMR demonstrates significant morphological differences between the G+/LVH- population and healthy controls. Further studies are needed to assess the prognostic significance of these morphological features.

Predictors of genotype-positive status Variables G+ subjects (n = 33) Controls (n = 35) P value OR for G+ status P value Left ventricular mass/BSA (g/m²) 45 ± 7.4 53 ± 7.9 <0.001 0.86 [0.78-0.95] 0.003 Right ventricular ejection fraction (%) 58 ± 6 53 ± 4 <0.001 1.15 [1.00-1.32] 0.047 Crypts 17 (55%) 4 (11%) <0.001 9.62 [1.93-48.00] 0.006 G+: genotype-positive, OR: odds ratio Abstract Figure. CMR findings

P1825 Myocardial bridging and coronary artery disease in hypertrophic cardiomyopathy: a matched case control study

Funding Acknowledgements

None.

Introduction

The etiology of chest pain in hypertrophic cardiomyopathy (HCM) is diverse and includes coronary artery disease (CAD) as well as HCM-specific causes. Myocardial bridging (MB) has been associated with HCM, chest pain, and accelerated atherosclerosis. To investigate differences in the presence of MB and CAD, we compared HCM patients with age-, gender- and CAD pre-test probability (PTP)-matched outpatients presenting with chest pain.

Methods

We studied 84 HCM patients who underwent cardiac computed tomography and compared these with 168 matched controls (age 54 ± 11 years, 70% men, PTP 12% [5%–32%]). MB, calcium score, plaque morphology and presence and extent of CAD were assessed for each patient. Linear mixed models were used to assess differences between cases and controls.

Results

Differences between HCM patients and controls are described in the table. In summary, MB was more often seen in HCM patients (50% vs. 25%, p < 0.001), who were also more likely to have >1 segment affected (14% vs. 2%, p < 0.05). In the HCM group, MB was associated with pathogenic mutation status. Calcium score and the presence of obstructive CAD were similar in both groups (9 [0-225] vs. 4 [0-82] and 18% vs. 19%; p > 0.05 for both).

Conclusion

MB was twice as prevalent in the HCM group. However, in a matched analysis, the prevalence and extent of CAD was equal among patients with and without HCM. These finding illustrate that despite a higher prevalence of MB, the prevalence of CAD is similar between groups, also demonstrating satisfactory performance of pre-test risk prediction in HCM patients.

Assessment of CAD by CT HCM group(n = 84) Control group (n = 168) p-value Agatston score 9 [0-225] 4 [0-82] 0.22 No. of pts with score* 0.07 0-399 31 (89%) 149 (91%) >400 8 (11%) 15 (9%) Obstructive CAD 15 (18%) 32 (19%) 0.82 No. of pts with MB 42 (50%) 42 (25%) <0.001 No. of vessels with MB <0.001 1 34 (40%) 39 (23%) 2 8 (10%) 3 (2%) No. of pts with >1 segment with MB 12 (14%) 4 (2%) <0.001 Abbreviations CAD = Coronary artery disease, MB = Myocardial bridging, pts = patients *Only measured in 73/84 HCM patients and in 164/168 control patients

P1818Descending aortic thoracic diameter: a risk marker for major adverse cardiovascular outcomes in women

Background

Thoracic aortic diameters have been associated with cardiovascular risk factors and atherosclerosis. However, limited evidence regarding the role of thoracic aortic diameters as risk markers for major cardiovascular outcomes among women and men exist.

Purpose

To evaluate the independent associations between crude and indexed ascending and descending aortic (AA and DA) diameters with major cardiovascular outcomes among women and men and to provide optimal cutoff values associated with increased cardiovascular risk.

Methods and results

2178 women and men ≥55 years from the prospective population-based Rotterdam Study underwent multi-detector CT scan of thorax. Crude diameters of the AA and DA were measured and indexed by height, weight, body surface area (BSA) and body mass index (BMI). Incidence of stroke, coronary heart disease (CHD), heart failure (HF), cardiovascular and all-cause mortality were evaluated during 13 years of follow-up.

Weight-, BSA-, or BMI-indexed AA diameters showed significant associations with total or cardiovascular mortality in both sexes and height-indexed values showed association with HF in women. Crude AA diameters were associated with stroke in men and HF in women. For DA, crude and almost all indexed diameters showed significant associations with either stroke, HF, cardiovascular or total mortality in women. Only weight-, BSA- and BMI-indexed values were associated with total mortality in men. For crude DA diameter, the risk for stroke increased significantly at the 75th percentile among men while the risks for HF and cardiovascular mortality increased at the 75th and 85th percentiles respectively in women.

Conclusions

Our study suggests a role for descending thoracic aortic diameter as a marker for increased cardiovascular risk, in particular for stroke, heart failure and cardiovascular mortality among women. The cut points for increased risk for several of cardiovascular outcomes were below the 95th percentile of the distribution of aortic diameters.

P6170Incremental value of on-site computed tomography-derived fractional flow reserve for the diagnosis and management strategy of obstructive coronary artery disease in the randomized CRESCENT trials

Background

Coronary computed tomography angiography (CCTA) accurately rules out coronary artery disease (CAD), but has a limited ability to predict hemodynamically significant CAD. Implementing on-site computed tomography-derived fractional flow reserve (CT-FFR) could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with stable angina.

Purpose

To determine the impact of on-site CT-FFR on diagnostic effectiveness, management strategy and downstream invasive coronary angiography (ICA) in patients with suspected CAD.

Methods

196 patients (59.1±9.6 years, 47% women) with suspected CAD underwent a CCTA in the CRESCENT I and II trials. On-site CT-FFR analysis was performed in all patients with at least one ≥50% stenosis on CCTA (N=53). We assessed the effect of adding CT-FFR analysis to CCTA in terms of 1) diagnostic effectiveness, i.e. the number of additional tests required to determine the final diagnosis; 2) reclassification of the initial management strategy; 3) ICA efficiency, i.e. ICA rate without ≥50% CAD.

Results

CT-FFR was calculated in 42/53 (79%) of the eligible patients as it could not be calculated in patients with suspected coronary total occlusion (N=7), severe coronary calcification (N=2), severe CT artefacts (N=1) or missing CT images (N=1). CT-FFR ≤0.80 was present in 27/196 (14%) patients, including 8/196 (4%) patients with high-risk ischemia (CT-FFR ≤0.80 in all three vessels, left main or proximal left anterior descending coronary artery). The final diagnosis was achieved with CT-FFR in an additional 30/196 (15%) patients compared to CT alone (p<0.0001), and rendered 42/56 (75%) of additional tests unnecessary (p<0.0001). The initial management strategy was reclassified in 30/196 patients (15%, p<0.0001); 24/196 (12%) patients were reclassified to optimal medical therapy and 6/196 (3%) patients were reclassified directly to ICA including 4/8 (50%) patients with high-risk CAD on ICA. CT-FFR would result in 6/32 (19%, p=0.012) ICA cancellations in which none of the patients had high-risk CAD. The rate of ICA without ≥50% stenosis would decrease from 22% (7/32) to 11% (3/27) (p=0.012).

Conclusion

Implementation of CT-FFR has the potential for improved diagnostic effectiveness. Functional reclassification of CAD provides more efficient ICA referral in patients with suspected CAD compared to CTA alone.

Acknowledgement/Funding

Dutch Heart Foundation [NHS 2014T061 and NHS 2013T071]

Endoscopic exposure and stabilization of posterior and inferior branches using the endo-starfish cardiac positioner and the endo-octopus stabilizer for closed-chest beating heart multivessel CABG: hemodynamic changes in the pig

BACKGROUND

Closed-chest, off-pump, multivessel CABG requires modified instruments to expose and stabilize posterior and inferior coronary branches. Using three new prototype devices, we explored the feasibility of endoscopic bypass grafting on these branches and assessed cardiac function during cardiac displacement.

METHODS

Eight pigs (75 to 85 kg) were instrumented for hemodynamics and paced at 80 to 100 bpm. After closure of the sternotomy wound, the Da Vinci endoscope was inserted subxiphoidally. A sternal hook was used to hoist the sternum ventrally by 5 cm. The articulating EndoStarfish cardiac positioner was placed through a trocar (Ø12 mm). The positioner was fixed to the apex using -400 mm Hg suction and the heart was displaced anteriorly to 90 degrees. In 12 other pigs (75 to 85 kg), both internal mammary arteries (IMA) were harvested and the sternal wound was closed. Five trocar ports were placed for instrumentation (Ø12 mm, two in left chest, two in right chest, and one subxiphoidally). For coronary stabilization, a novel deployable EndoOctopus cardiac stabilizer was employed (suction -400 mm Hg). The Da Vinci robot-telemanipulator system was used for endoscopic grafting of the left and right IMA on posterior and inferior branches (16 anastomoses).

RESULTS

When circumflex arteries were fully exposed and accessible for coronary surgery, stroke volume decreased by 18%+/-3 versus baseline (P=0.02) and mean arterial pressure decreased by 27%+/-6 (P=0.001). Additional 10 degrees Trendelenburg head-down positioning normalized stroke volume and arterial pressure. In the displaced heart, obtuse marginal branches (OM) and the ramus descending posterior (RDP) of the right coronary artery became fully exposed with a mean arterial pressure >70 mm Hg during grafting. No accidental detachment occurred. Coronary target motion was restrained to approximately 1x1 mm. In two test cases, five sham distal anastomoses were created (grafts sewn to epicardium, left IMA to OM2 jump to OM3, right IMA to RDP, and composite graft from left IMA jump to diagonal branch). In 10 animals, 16 successfully completed anastomoses to RPD and OM branches of Ø1.75 to 2.5 mm required 25 to 60 minutes each to construct. At sacrifice, all anastomoses were patent.

CONCLUSIONS

In the closed-chest pig in Trendelenburg position and during lifting of the sternum, the EndoStarfish and EndoOctopus enabled IMA grafting of posterior and inferior branches on the beating heart without mean arterial pressure dropping below 70 mm Hg.

[Myositis proliferans. Differential cervical space-occupying lesion diagnosis]

Myositis proliferans is a rare and benign pseudosarcomatous tumour of soft tissue. In most cases it is found in the region of the shoulder and arm and its occurrence in the region of the neck is described in literature in 16 cases in all. For the ear, nose and throat specialist it is an important differential diagnosis in contrast to malignant tumours. In this report we present the cases of two patients, who were suffering from painful cervical swelling that had been increasing for some days. The problems inherent in the diagnosis of this illness are discussed. Due to its rapid growth the tumour is generally falsely diagnosed and radically removed. Therefore, in appropriate case history, this possibility should be considered and excluded in order to prevent the patient from unnecessary radical operation. In addition to clinical symptoms, imaging and trial excision are suitable.

[Schwannoma of the tongue]

BACKGROUND

Schwannoma, in the English literature mostly called neurilemmoma, are well known in the ear-nose-and-throat-medicine as benign tumors of the nerve-sheath, for example as neuroma of the acoustic nerve. They are seldom found at other peripheral nerves of the head. The localisation in the tongue has so far only been described in some individual cases.

CASE REPORT

We present a case of a 28-year-old woman with a schwannoma of the tongue, measuring 4.0 x 2.2 x 3.2 cm. The case history and the radiological investigations suggested a malignant tumor. During the operation the lump revealed itself as being encapsulated. Under the histological examination it was discovered to be a Schwannoma.

CONCLUSIONS

We would like to add a further case of a schwannoma of the tongue to the so far published cases, thus allowing this possibility to be considered in general diagnosis.

Enzyme and immunohistochemical studies on acute monocytic leukemia (FAB M5): proposal for a new immunohistochemical subclassification

Using only morphological criteria as proposed by the French-American-British (FAB) Study Group, the subclassification of acute monocytic leukemia (FAB M5) into the categories M5a and M5b can be difficult. We therefore investigated 13 cases of well-established M5 leukemias. The results show that immunohistochemical techniques allow a better subdivision of the acute monocytic leukemias. The less-mature types are characterized by a focal lysozyme and a negative CD68 reaction, whereas the more differentiated types express a diffusely positive lysozyme and also a positive CD68 phenotype: a staining pattern also found in the rare true histiocytic lymphomas. We regard these results as a useful addition to the FAB classification.

[Computer-assisted monitoring in the neonatal intensive care unit]

Computerized monitoring in a neonatal intensive care unit allows continuous registration and complete storage of vital parameters. The stored data can be used for detailed retrospective analysis of critically ill patients and the graphical presentation of the vital parameters may lead to an earlier recognition of clinical deterioration. This computer system which can be established in any intensive care unit demonstrates the improvement in neonatal intensive care monitoring at low financial costs.

Alcoholic dyshaematopoiesis: morphological features of alcohol-induced bone marrow damage in biopsy sections compared with aspiration smears

We investigated trephine biopsies from 118 alcoholic patients in order to establish whether or not the known alcohol-induced alterations seen in smears are seen in bone marrow tissue sections, and whether new features might emerge, which could be suitable for defining the histological picture of a condition to be known as 'alcoholic dyshaematopoiesis'. The main changes involve erythropoiesis and iron metabolism. They can be attributed in part to destabilization of the red cell membrane. While these alterations are clearly visible in tissue sections, aspiration smears are needed to detect other features, especially ring sideroblasts.

Androstenedione metabolism in cultured human osteoblast-like cells

Bone is a target organ of androgens. The mechanism by which these steroids exert their action within bone cells is still poorly understood. The metabolism of androstenedione, the major circulating androgen in women, was, therefore, assessed in osteoblast-like bone cells cultured from bone of 16 postmenopausal women (mean age, 69 yr; range, 56-80) and 3 elderly men (mean age, 71 yr; range, 69-73) undergoing total hip replacement. Each cell strain was incubated under standardized conditions with varying concentrations of [1,2,6,7-3H]androstenedione (0.05-5 microM). In every instance 5 alpha-reduced metabolites and 17 beta-hydroxysteroids were formed. There was no correlation between the volumetric density of the resected bone and androstenedione metabolism of the corresponding cultured bone cell strains. The apparent Km for the 5 alpha-reductase activity (sum of androstanedione and dihydrotestosterone) of all 19 cell strains was 0.7 +/- 0.1 microM (mean +/- SEM), and the apparent Km for 17 beta-hydroxysteroid dehydrogenase (sum of testosterone and dihydrotestosterone) was 2.3 +/- 0.8 microM (mean +/- SEM), values similar to those reported for other androgen target organs. Our results demonstrate that human osteoblast-like cells have the capacity to transform androstenedione into the more potent biological androgens testosterone and dihydrotestosterone. Since the Km values of both 5 alpha-reductase and 17 beta-hydroxysteroid dehydrogenase exceed the serum androstenedione concentration, the formation of testosterone and dihydrotestosterone appears to be mainly a function of substrate availability.

Smokers' dysmyelopoiesis--bone marrow alterations associated with cigarette smoking

Cigarette smoking is frequently associated with leukocytosis (with normal differential count) and polyglobulia in the peripheral blood. Corresponding studies on bone marrow alterations in smokers have not been done until now. We therefore investigated bone marrow trephine biopsies of 32 smoking persons. Biopsies had been mainly performed because of mild peripheral leukocytosis. In all cases we found a moderate increase in granulopoietic cells with a significant shift to the right and a distinct stimulation of phagocytic activity in macrophages. According to cytochemical findings, neutrophils are the major target of this phagocytic activity. We interpret these results as a smoking induced inhibition of locomotion in segmented neutrophils leading to an accumulation of mature polymorphs in the bone marrow with consecutive break-down and phagocytosis of senescent cells. We propose the designation "smokers' dysmyelopoiesis" for these changes.

[Stepladder accidents--a 5-year analysis of these falls from a height]

156 injuries by a stepladder are reported. In the whole of plunge injuries occurred with a stepladder we found 12%. The painters are involved in 34.6% in this kind of accident, apprentices in 5.8%. Most people were aged from 20-24 and the lower limb was more often injured than the upper limb. Fractures were present in 24% and we registered 48.8 days in which workers were unfit to work. Most patients (95.2%) obtained total rehabilitation.

Investigations on beta-glucuronidase-positive erythrocytic inclusions

Novel erythrocytic inclusion bodies, characterized by strong beta-glucuronidase activity, are described. Their physicochemical properties differ substantially from those of known inclusion bodies and they are mainly observed in patients with liver damage. Since these inclusions occur almost exclusively in erythrocytes, the intraerythrocytic beta-glucuronidase must originate from an extraerythrocytic source, perhaps entering erythrocytes via a receptor-mediated endocytotic pathway.

Beta-glucuronidase-positive erythrocytic inclusion bodies--a hitherto unknown phenomenon

A combined cytochemical and electron microscopical study has delineated a new type of an erythrocytic inclusion body. Enzyme cytochemically these inclusions are characterized by beta-glucuronidase as a marker enzyme. In part, the inclusions may contain acid phosphatase and ferritin. The inclusions develop in mature erythrocytes since beta-glucuronidase normally does not occur in erythroblasts and, in general, this type of inclusion body is not found in erythroblasts. Based upon our preliminary findings, the hypothesis is extended that beta-glucuronidase is taken up via receptor-mediated endocytosis into erythrocytes and is finally put into clustered cytolysosomal vaculoes, that account for the inclusion bodies as seen at light microscopy. Exogenous beta-glucuronidase might be contributed for by breakdown of cells (e.g. hepatocytes) producing this enzyme in considerable amounts numbers. This view is corroborated by the observation that most patients with beta-glucuronidase-positive inclusions suffered from various chronic disorders of the liver.

[New aspects of the surgical treatment of chronic lymphedema]

Experiences are presented of a method of improving lymph drainage by implantation of silicone tubing in cases of lymphoedema of the arm following treatment of breast cancer. The passive drainage of lymph from the arm to the abdominal fat leads to a reduction of volume of 20%. Detailed long term clinical results are described and the drainage of lymph is demonstrated.

Cytochemical investigations of phagocytes in thyroid gland cysts

Certain similarities in the cytoplasmic structure could indicate a histogenetic affinity between thyrocytes and pigmented macrophages in thyroid glands. On the other hand, the monocytogenic origin of macrophages in other organs in the body contradicts this assumption. We investigated these cells in smears of thyroid aspirates as well as in imprints, frozen sections and paraffin-embedded sections of freshly removed thyroid glands, using several cytochemical reactions and the usual panoptic stains. With the sodium-fluoride-inhibited alpha-naphthyl acetate esterase and tartrate-inhibited acid phosphatase reactions, the pigmented macrophages exhibited enzyme cytochemical patterns corresponding to those of blood monocytes or monocytogenic histiocytes but differing definitely from those of thyrocytes. Furthermore, we observed macrophages that exhibited a clearly monocytoid nuclear form and chromatin pattern in the interstitial space of the thyroid gland. These findings practically exclude a derivation of thyroidal pigmented macrophages from follicular epithelial cells and positively underline their derivation from blood monocytes.

[A new method for managing epistaxis in Osler's disease (author's transl)]

We describe a new method for successful management of epistaxis in patients with hereditary hemorrhagic telangiectasias. By so doing, even pulmonary arteriovenous fistulas and gastrointestinal hemorrhages can be successfully managed. During a four year period, 14 patients were treated with an oral contraceptive preparation which combined a reduced dosage of estrogen and progesterone. With this therapy, 11 patients stopped bleeding while 3 responded with significant improvement. We believe that this effect on bleeding by the hormone therapy is a sign of an abnormal increase of specific hormone requirements in patients with Osler's disease.