BRUCELLOSIS COMPLICATED BY AORTIC VALVE ENDOCARDITIS

A 30 year old veterinary surgeon developed a febrile illness with serological evidence of Brucellosis. He was known to have aortic valve disease and during the course of the illness, the clinical features of endocarditis became evident, with a vegetation visible echocardiographically on the aortic valve. Because of persisting fever despite appropriate antibiotic therapy, aortic valve replacement with a viable cryopreserved allograft aortic valve was undertaken. Organisms consistent with Brucella species were demonstrated in the excised vegetation. The patient received a six week course of antibiotics and his post-operative course was uneventful.     

An unusual pattern of metastases from Merkel cell carcinoma

An unusual case of Merkel cell carcinoma is presented in which the time course to development of nodal and haematogenous metastases was protracted and the predominant site of metastatic disease was small bowel.     

Aetiology of non-immune hydrops: the value of echocardiography

Summary. Forty-eight pregnancies, five of them multiple, were referred for fetal cardiac assessment following the detection of non-immune hydrops fetalis; there were 52 hydropic fetuses in total. A cardiovascular aetiology was found in 21 of these 52 (40%); structural heart disease was present in 13, tachyarrhythmia in the remaining eight. The accurate delineation of these causes was possible using fetal echo-cardiography, and enabled rational management to be instituted. This included termination of pregnancy, pharmacological control of arrhythmias and appropriate timing of delivery.     

Effect of epidural analgesia on maximum and minimum blood pressures during the first stage of labour in primigravidae with mild/moderate gestational hypertension

Summary. One of the arguments used in favour of epidural analgesia for hypertensive patients in labour is its effect on mean arterial blood pressure, although the fetal and maternal risk from hypertension is more closely linked to maximum recorded levels. We have therefore assessed the effect of epidural analgesia on maximum blood pressure. There was no change in the maximum systolic or diastolic blood pressure after epidural analgesia when compared to baseline values or levels in untreated hypertensive controls. We conclude that this form of analgesia should be offered to hypertensive patients purely for its analgesic effect and not as a method for blood pressure control.     

Tinnitus in pregnancy

The presence of tinnitus in pregnancy was investigated by a postal questionnaire survey. A group of pregnant women attending the ante-natal clinic and a control group of non-pregnant members of the nursing staff at the Royal United Hospital in Bath were studied. The prevalence of tinnitus in the pregnant and non-pregnant women was compared. Both groups were similar in age, previous noise exposure and the presence of ear disease or operations. Twenty-five per cent of the pregnant women reported tinnitus compared with 11% of the control group. Chi-square analysis of this data gives a value of χ²= 4.07, d.f. = 1, P < 0.05. The result of our survey shows that there is a significantly increased prevalence of tinnitus in pregnant women compared with a similar non-pregnant control group. This association has not been previously reported.     

INTRAVENOUS GLUCOSE TOLERANCE, PLASMA INSULIN, FREE FATTY ACIDS AND β-HYDROXYBUTYRATE IN UNDERWEIGHT NEWBORN INFANTS

Blood glucose, plasma insulin, FFA and β-hydroxybutyrate values during intravenous glucose tolerance were reported in 20 small for gestational age (SGA) and 15 appropriate for gestational age (AGA) low birthweight infants. The babies were divided into three groups according to their age when tested; <24 hours, 24–48 hours and >48 hours. Both the SGA and AGA infants cleared glucose more rapidly with increasing age. The change was more marked in the SGA babies. The clearance rates were similar to those reported in normal full-sized infants. The insulin values before the glucose load were similar in all groups and comparable to those reported in normal newborn infants. The insulin response to glucose was variable. There were no significant differences with increasing age or between the two groups of infants. The insulin curve of the individual infant followed one of three patterns. Most commonly seen was a double-peak curve. The infants who showed a single-peak insulin response had a better but not significantly different glucose tolerance than that of the other babies. Infants with no appreciable insulin response still removed glucose from plasma at a rate similar to those with a double-peak insulin curve. It is concluded that insulin as measured in peripheral plasma could not explain the rate of removal of glucose from the plasma of the newborn low birthweight infant. Infants of low birthweight had higher plasma FFA values as compared to that reported in normal full term infants. The FFA values in SGA infants were higher than those in AGA babies. In both groups of infants, the jS-hydroxybutyrate values were comparable to those reported in normal full-term babies. Thus there was an unexpected discrepancy between the high FFA and relatively low β-hydroxybutyrate levels in plasma. The fall in plasma FFA and β-hydroxybutyrate after glucose was minimal but similar in both groups of infants. The findings are compatible with a decreased sensitivity to insulin in the infants studied.     

Gross and Microscopic Changes Associated with a Nonthoracotomy Implantable Cardioverter Defibrillator

The pathology associated with an invesrigational transvenous defibriliating and sensing lead is described. The lead system had delivered a total of 865 J from the time of implantation to the time of patient death from a noncardiac cause 7 months after implantation and 1 month after his last defibrillator shock. There was mild, superficial fibrous thickening on the endothelial surface of the superior vena cava adjacent to the proximal spring electrode, which did not extend into the vessel wall. The distal portion of endocardial lead was embedded in the interventricular septum near the apex of the right ventricle, surrounded by fibrous thickening, and partially covered by endocardial tissue. Microscopically, there was a thick bed of fibrous connective tissue surrounding the lead with extensive interstitial fibrous connective tissue radiating into the adjacent myocardium. Since this pattern is different from the more generalized fibrotic scarring produced by myocardial infarction, we speculate that the mechanism for the observed interstitial fibrosis is replacement fibrosis following acute myocyte injury that resulted from prior defibrillator shocks and possibly from the trauma produced by the lead compressing adjacent myocardium during systole. Potential effects on device efficacy of these fibrotic changes at the bioelectric interface include their representing a new arrhythmia substrate, the possibility that fibrosis could increase both defibrillation and pacing thresholds, and that the inflammatory reaction may cause deterioration of intracardiac electrograms and interfere with sensing and tachycardia recognition.     

Visceral Leishmaniasis Complicating Polycythemia Vera

Abstract. A case of visceral leishmaniasis is presented, where a pre-existing polycythemia vera obscured signs of the infection. Visceral leishmaniasis is a life-threatening but curable protozoan infection of the reticuloendothelial system. We wish to report a case where symptoms and signs were obscured by a preexisting hematologic disease, polycythemia vera.     

NASPE POLICY STATEMENT The NASPE* BPEG** Defibrillator Code

BERNSTEIN, A.D., et al .: The NASPE/BPEG Defibrillator Code. A new generic code, patterned after and compatible with the NASPE/BPEG Generic Pacemaker Code (NBG Code) was adopted by the NASPE Board of Trustees on January 23, 1993. It was developed by the NASPE Mode Code Committee, including members of the North American Society of Pacing and Electrophysiology (NASPE) and the British Pacing and Electrophysiology Group (BPEG). It is abbreviated as the NBD (for NASPE/BPEG Defibrillator) Code. It is intended for describing the capabilities and operation of implanted cardioverter defibrillators (ICDs) in conversation, record keeping, and device labeling, and incorporates four positions designating: (1) shock location; (2) antitachycardia pacing location; (3) means of tachycardia detection; and (4) antibradycardia pacing location. An additional Short Form, intended only for use in conversation, was defined as a concise means of distinguishing devices capable of shock alone, shock plus antibradycardia pacing, and shock plus antitachycardia and antibradycardia pacing. (PACE, Vol. 16, September 1993)