Bezold-Jarisch-Like Phenomenon Induced by Radiofrequency Ablation of a Left Posteroseptal Accessory Pathway via the Coronary Sinus

RF Ablation-Induced Bezold-Jarisch Phenomenon. We report a case of asystole induced by radiofrequency (RF) ablation via the coronary sinus in a 35-year-old man suffering from symptomatic left posteroseptal accessory pathway. RF application provoked progressive slowing of the sinus rhythm, disappearance of the preexcitation, and an 8-second period of asystole followed by atrial fibrillation. The causal mechanism proposed is a strong stimulation of va-gal afferent pathways linked with sensory endings of the inferoposterior myocardial wall leading to a Bezold-Jarisch-like phenomenon.     

Pathology of human intestinal transplantation

BACKGROUND & AIMS: Intestinal transplantation is a developing therapeutic option for patients with irreversible intestinal failure or short bowel syndrome. The aim of this study was to delineate the histopathology of human intestinal allografts and to define the features of intestinal rejection. METHODS: The histological features of 3015 endoscopic biopsy specimens and 23 allograft specimens from 62 intestinal recipients were analyzed retrospectively and correlated with clinical findings. RESULTS: Acute allograft rejection was characterized by a varying combination of crypt injury, mucosal infiltration primarily by mononuclear cells (including blastic lymphocytes), and increased crypt cell apoptosis (more than 2 per 10 crypts). It represented a patchy, often ileal-centered process that could progress to mucosal ulceration; later episodes (more than 100 days posttransplant) tended to show lesser cellular infiltration and greater apoptosis than earlier episodes. Correlation with clinical rejection was good (false-positive rate of 9%; false-negative rate of 26%). Two resected specimens showed obliterative arteriopathy indicative of chronic rejection. In other specimens, preservation injury, cytomegalovirus infection, post-transplant lymphoproliferative disorder, and nonspecific features of active or past mucosal injury could be recognized. CONCLUSIONS: Mucosal biopsy specimens are a useful means of monitoring intestinal allografts. Based on features validated by clinical correlation, acute rejection can be identified reliably and can be differentiated from the other pathological processes affecting the intestinal allograft. (Gastroenterology 1996 Jun;110(6):1820-34)     

Gastroesophageal reflux in very low birth weight infants: association with chronic lung disease and outcomes through 1 year of age.

OBJECTIVE: To analyze the association between chronic lung disease (CLD) and clinically diagnosed gastroesophageal reflux (GER) in very low birth weight (VLBW) infants, and between GER and outcomes at 1 year adjusted age. METHODS: A total of 375 consecutively born VLBW infants with CLD and 345 gestational age-matched controls were studied. Records were reviewed to ascertain which infants were diagnosed with GER (based on clinical suspicion or confirmatory tests) and which infants had delayed growth or development at 1 year adjusted age. RESULTS: Infants with CLD were treated for GER more frequently than controls (CLD: 27% versus controls: 9%; p < 0.0001). Among infants with CLD, those with and without GER were comparable in terms of the days on supplemental oxygen [124 (64 to 93) vs 121 (47 to 394)] and the proportion with cystic changes on chest radiograph (44% vs 47%). Comparing outcomes at 1 year for infants with and without GER, no differences were found in the rates of Bayley Mental Developmental and Psychomotor Developmental Indices of < 70, cerebral palsy, and measurements below the 10th percentile. CONCLUSION: Among VLBW infants, an association exists between CLD and GER, although this association might be due to greater diagnostic suspicion in infants with CLD. In VLBW infants, GER does not appear to increase the risk of delayed growth or development.     

Patch closure of aortic annulus mycotic aneurysms

Twenty-three patients with bacterial endocarditis and mycotic aneurysms of the aortic annulus were treated between 1978 and 1985. There were 18 men and 5 women ranging from 24 to 72 years old. All patients had congestive heart failure and positive blood cultures as a complication of the endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. The aneurysm complicated late prosthetic valve endocarditis in 7 patients and native valve endocarditis in 16. The most common infecting organisms were streptococci (12 patients) and staphylococci (7 patients). The noncoronary sinus was the most frequent site for aneurysm formation. Following debridement of the abscess cavity, the orifice of the aneurysm was closed with a patch of Dacron in 20 patients and autologous pericardium in 3. A prosthetic valve (18 bioprosthetic and 5 mechanical) was secured to the noninfected portion of the native annulus and to the patch at the level of annulus. There were 3 deaths, 1 perioperative and 2 late, each without evidence of residual infection or aortic insufficiency. There are 20 late survivors (87%). After a mean follow-up of 1 year, all patients are in NYHA Functional Class I. Patch closure of mycotic aneurysms involving the aortic annulus permits aggressive debridement of the abscess cavity and affords closure of the orifice without tension. The prosthetic valve can be seated at the level of the native annulus, thus avoiding complicated reconstructive procedures of the aortic root and coronary arteries. This technique is an effective alternative in selected cases of mycotic aneurysms involving the aortic annulus.     

Neonatal treatment with 192 IgG-saporin produces long-term forebrain cholinergic deficits and reduces dendritic branching and spine density of neocortical pyramidal neurons

The role of basal forebrain-derived cholinergic afferents in the development of neocortex was studied in postnatal rats. Newborn rat pups received intraventricular injections of 192 IgG-saporin. Following survival periods ranging from 2 days to 6 months, the brains were processed to document the cholinergic lesion and to examine morphological consequences. Immunocytochemistry for choline acetyltransferase (ChAT) and in situ hybridization for ChAT mRNA demonstrate a loss of approximately 75% of the cholinergic neurons in the medial septum and nucleus of the diagonal band of Broca in the basal forebrain. In situ hybridization for glutamic acid decarboxylase mRNA reveals no loss of basal forebrain GABAergic neurons. Acetylcholinesterase histochemistry demonstrates a marked reduction of the cholinergic axons in neocortex. Cholinergic axons are reduced throughout the cortical layers; this reduction is more marked in medial than in lateral cortical areas. The thickness of neocortex is reduced by approximately 10%. Retrograde labeling of layer V cortico-collicular pyramidal cells reveals a reduction in cell body size and also a reduction in numbers of branches of apical dendrites. Spine densities on apical dendrites are reduced by approximately 20-25% in 192 IgG- saporin-treated cases; no change was detected in number of spines on basal dendrites. These results indicate a developmental or maintenance role for cholinergic afferents to cerebral cortical neurons.      

Oxygen supplementation during air travel in patients with chronic obstructive lung disease.

The objective of this study was to quantitate the effects of O2 supplementation by nasal cannula (NC) and Venturi mask (VM) on PaO2 in patients with chronic obstructive pulmonary disease (COPD) during acute hypobaric exposure, simulating a commercial jet aircraft cabin. We conducted a crossover intervention trial in which subjects served as their own controls in an ambulatory outpatient pulmonary disease service of a tertiary care military medical center and a hypobaric research facility. The subjects were a volunteer sample of 18 men with stable severe COPD, not requiring long-term O2 therapy, and uncomplicated by hypercapnea or cardiac disease. Mean age was 68 years, and mean FEV1 was 0.97 L (31.3 percent predicted). We exposed patients to conditions equivalent to 8,000 feet in a hypobaric chamber. Radial artery catheters provided blood samples at ground level and 8,000 feet. O2 was sequentially administered at 8,000 feet by NC at 4 L/min and 24 percent or 28 percent VM. We describe changes in blood gas data from baseline values and between interventions. O2 at 4 L/min NC flow at 8,000 feet caused PaO2 to increase from 47.4 +/- 6.3 mm Hg to 82.3 +/- 14 mm Hg (n = 18), an increase of 34.9 +/- 14.8 mm Hg. Supplementation of O2 by 24 percent VM caused PaO2 at 8,000 feet to increase by 12.7 +/- 3.8 mm Hg. Twenty-eight percent VM caused PaO2 at 8,000 feet to increase by 19.7 +/- 8.2 mm Hg. Changes in PaO2 with 4 L/min NC were greater than those with either VM. The increase with 28 percent VM was greater than that caused by 24 percent VM (p less than 0.05). Compared with ground level, 4 L/min NC increased mean PaO2 by 9.9 +/- 12.6 mm Hg; 24 percent and 28 percent VM did not cause mean PaO2 to increase above ground level values. We describe a range of capability of familiar O2 therapy devices to increase PaO2 to levels that will maintain tissue oxygenation of patients during acute altitude exposure.     

Primary splenic tuberculosis in transplant candidates.

Caseous granulomatous lesions, consistent with tuberculosis, were found in the spleen in two of our renal transplant candidates. There was no clinical evidence of tuberculosis in either patient. Only one patient had a positive tuberculin skin test whose chest film showed hilar calcifications suggestive of healed granulomatous disease. Because of this incidental finding in the spleen, both patients were placed on antituberculous therapy. There has been no evidence of active tuberculosis in either patient despite the use of usual doses of immunosuppressive drugs.     

High output cardiac failure secondary to a Brescia-Cimino fistula.

A patient with high output cardiac failure secondary to a Brescia-Cimino fistula is presented. The heart failure responded to a reduction in the fistula size. The literature on this complication is reviewed.