A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral‐aortic intervalvular fibrosa

A 28‐year‐old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three‐dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26‐mm‐long pouch was seen in mitral‐aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.     

Nintendo® Wii Fit based sleepiness tester detects impairment of postural steadiness due to 24 h of wakefulness

A field-usable sleepiness tester could reduce sleepiness related accidents. 15 subjects’ postural steadiness was measured with a Nintendo^® Wii Fit balance board every hour for 24 h. Body sway was quantified with complexity index, C_I, and the correlation between C_I and alertness predicted by a three-process model of sleepiness was calculated. The C_I group average was 8.9 ± 1.3 for alert and 7.9 ± 1.4 for sleep deprived subjects (p < 0.001, ρ = 0.94). The Wii Fit board detects the impairment of postural steadiness. This may allow large scale sleepiness testing outside the laboratory setting.     

Men in kindergartens: work culture and gender

This article examines the impact on work culture when men work in kindergartens. In Norway, as in other countries there has been a call for more male staff in kindergartens. Increasing the amount of men may imply that institutionalized norms and practice are put under pressure. By using a case study approach, the focus is on employees’ experiences and practice in daily life in the kindergarten. Two processes, negotiation about work organization and the division of labour, illustrate the empirical part of this article. The findings indicate that female staff negotiate for standardized workdays and norms of sameness, while the males negotiate for a flexible workday and division of labour based on their interests. The difference in practice between males and females and negotiation about the division of labour contribute to constructing gendered work cultures.     

Abgrenzung Diagnosefehler zu Befunderhebungsfehler

In medical malpractice allegations the burden of proof is often crucial to the outcome of the proceedings. In principle, the burden of proof is assigned to the complainant (patient) and only in exceptional cases, especially in the presence of a gross error in treatment, is the burden of proof reversed so that the defendant (physician) has to prove that the treatment did not cause injury to the patient. To supply this proof is of course very difficult. In this context a judgment of the Federal Court of Justice (BGH) from December 2010 achieves a special significance which, in conjunction with an earlier BGH ruling in April 2004, provides that this reversed burden of proof applies even for a slight error in assessment of findings but in contrast only for a very serious diagnostic error. The failure to recognize assessment of findings as medically necessary thus represents the considerably more medicolegally serious offence of medical misdemeanour. On the other hand, a much larger scale diagnostic error is classified as an ultimately not always avoidable medical error that can occur without negligence. From the perspective of practitioners it is recommended that a diagnosis (at least a tentative diagnosis) should be derived on the basis of the findings obtained or if this does not appear possible to initiate other necessary diagnostic measures. From the perspective of the medical expert, the expert recommendation is to always very carefully differentiate between these two medical errors in medical liability cases.     

Interaction between the photosensitizer lumichrome and human serum albumin: effect of excipients

Lumichrome (Lc) is a photodegradation product of riboflavin that can be used as a photosensitizer (PS) in antibacterial photodynamic therapy (aPDT). The binding of Lc with plasma proteins such as human serum albumin (HSA) could affect its efficiency as PS. Excipients are necessary to prepare stable formulations to be used in aPDT and they may affect the PS-HSA binding. Hydroxypropyl (HP)-α, β, γ-cyclodextrin (CD), polyethylene glycol 400 (PEG400) and Pluronic^® F-127 (PF127) were selected as model excipients in this study. The intrinsic HSA fluorescence quenching and absorption and fluorescence spectroscopy were used to evaluate the Lc-HSA interaction in the absence and presence of excipients. Nano-differential scanning calorimetry (DSC) was used to determine the effect of excipients on HSA. The photostability of the samples was also evaluated. The combined results showed a modest interaction between Lc and HSA which was reduced mainly by HPβCD. No major alterations of the HSA nano-DSC thermogram were observed after addition of excipients. HSA did enhance Lc photodegradation. The presence of PF127 did also induce photochemical destabilization of Lc independent of HSA. In conclusion, HPαCD, HPγCD and PEG400 seemed to be the excipients more suitable for use in topical preparations containing Lc.     

Unusual bifid crista galli in a patient with cleft lip and palate

One of the most common craniofacial malformations observed in newborn babies is cleft lip and palate (CLP). This syndrome presents with some anatomic variations. The aim of this study was to understand an anatomic variation of the crista galli that had not been reported previously in patients with CLP. A 17-year-old boy with CLP was referred to an orthodontic clinic for cone-beam computed tomography (CBCT) imaging before treatment. Axial and coronal sections and three-dimensional images showed that the crista galli had bifid heads that were attached to each other. Incomplete ossification had resulted in a bifid crista galli and the appearance of a suture in the anterior coronal section of the CBCT images. This anatomic variation could allow penetration of the anterior fossa during endoscopic surgery, which could be dangerous for the patient.     

Telemedicine support shortens length of stay after fast-track hip replacement

Background and purpose — Telemedicine could allow patients to be discharged more quickly after surgery and contribute to improve fast-track procedures without compromising quality, patient safety, functionality, anxiety, or other patient-perceived parameters. We investigated whether using telemedicine support (TMS) would permit hospital discharge after 1?day without loss of self-assessed quality of life, loss of functionality, increased anxiety, increased rates of re-admission, or increased rates of complications after hip replacement.

Patients and methods — We performed a randomized controlled trial involving 72 Danish patients in 1 region who were referred for elective fast-track total hip replacement between August 2009 and March 2011 (654 were screened for eligibility). Half of the patients received a telemedicine solution connected to their TV. The patients were followed until 1 year after surgery.

Results — Length of stay was reduced from 2.1 days (95% CI: 2.0–2.3) to 1.1?day (CI: 0.9–1.4; p < 0.001) with the TMS intervention. Health-related quality of life increased in both groups, but there were no statistically significant differences between groups. There were also no statistically significant differences between groups regarding timed up-and-go test and Oxford hip score at 3-month follow-up. At 12-month follow-up, the rates of complications and re-admissions were similar between the groups, but the number of postoperative hospital contacts was lower in the TMS group.

Interpretation — Length of postoperative stay was shortened in patients with the TMS solution, without compromising patient-perceived or clinical parameters in patients undergoing elective fast-track surgery. These results indicate that telemedicine can be of value in fast-track treatment of patients undergoing total hip replacement.     

A cautious iodization programme bringing iodine intake to a low recommended level is associated with an increase in the prevalence of thyroid autoantibodies in the population

Autoantibodies against the thyroid gland with thyroid peroxidase antibody (TPO‐Ab) and thyroglobulin antibody (Tg‐Ab) as the most common can often be demonstrated in serum. The effect of public iodization programmes on antibody prevalence is uncertain. Aim To measure the concentrations of thyroid autoantibodies in the Danish population before and after mandatory iodization of salt. Methods Two identical cross‐sectional population studies were performed before (Cohort 1 (C1), year 1997–1998, n = 4649, median urinary iodine 61 μg/l) and 4–5 years after (Cohort 2 (C2), year 2004–2005, n = 3570, median urinary iodine 101 μg/l) mandatory iodine fortification of salt was implemented in Denmark. Blood tests were analysed for TPO‐Ab and Tg‐Ab using sensitive assays. Results Antibodies were more frequent in C2 than in C1: TPO‐Ab > 30 U/ml, C1 vs C2: 14·3 vs 23·8% (P < 0·001) and Tg‐Ab > 20 U/ml, C1 vs C2: 13·7 vs 19·9% (P < 0·001). The C2 vs C1 effect was confirmed in multivariate regression models (C1 reference): TPO‐Ab: OR (95% CI): 1·80 (1·59–2·04) and Tg‐Ab: 1·49 (1·31–1·69). The increase in the frequency of thyroid antibodies was most pronounced in young women and especially observed at low concentrations of antibodies. Conclusion The prevalence of both TPO‐Ab and Tg‐Ab was higher 4–5 years after a cautious iodine fortification of salt was introduced in Denmark. The increase was most pronounced in young women and in the low concentrations of antibody. Further studies are needed to evaluate the long‐term effects of increased iodine intake on thyroid autoimmunity in the population.