Atypical forms of isolated partial atrioventricular septal defect increase the risk of initial valve replacement and reoperation.

OBJECTIVE: We consider the short- and long-term outcomes of the repair of the isolated partial atrioventricular (AV) septal defect to determine the role played by the atypical forms on the initial AV valve replacement and on the risk of reoperation. METHODS: Two hundred and eight patients underwent an operation for this malformation between 1974 and 2001. Clinical and echocardiographic examinations were performed on all patients, the AV valve regurgitation was graded from 1 to 4 and a residual interatrial shunt was sought. Median age at the intervention was 5.8 years (3 months to 67 years). RESULTS: Median follow-up time was 7.5 years (range 0-22.6 years). The cumulative 30-day, 5- and 20-year survival rates were 96.5, 95.4 and 94.6%, respectively. AV valve replacement was associated with a high mortality (P<0.001). A reoperation was performed on 12 patients (5.7%) including six patients within less than a 30-day period, especially to repair residual AV valve regurgitation. We performed four AV valve repairs by annuloplasty and six AV valve replacements. Two patients who had initially undergone an AV valve replacement underwent a reoperation for valve thrombosis. The cumulative 30-day, 5- and 20-year rates of freedom from reoperation were 96.5, 93.6 and 83%, respectively. An atypical form was present in 24 patients (11.5%) and was a risk factor for initial AV valve replacement (P<0.001) and for reoperation (P<0.001). A complete AV block occurred in 13 patients (6.2%), all of them within a 30-day period. The AV valve replacement was a high risk factor for a complete AV block (P<0.001). At the end of our study 180 patients (96%) were in NYHA I and 8 in NYHA II. CONCLUSIONS: The morbi-mortality of the isolated partial AV septal defect is primarily perioperative and is linked with the presence of an atypical form of the lesion. This atypical form was the main reason for reoperation for AV valve regurgitation. The AV valve replacement was associated with a high mortality and with the occurrence of complete AV block. Using a standardized technique, the AV septal defect can be repaired with excellent long-term clinical and echographic results.     

Inversion of Melatonin Circadian Rhythm in Chronic Alcoholic Patients during Withdrawal: Preliminary Study on Seven Patients

Aims: The inversion of melatonin circadian rhythm secretionin some alcoholics during both intake and acute withdrawal hasbeen widely reported. In the same way, what happens to thisinversion when these patients are in long-term withdrawal isnot known. To document this abnormality in alcoholics afterwithdrawal we investigated melatonin secretion observed duringchronic alcoholization and after withdrawal. Methods: We measuredthe urinary 6-sulfatoxymelatonin (6SM) (6SM/creatinine ratio),main metabolite of the hormone, in two fractions, one diurnaland the other nocturnal, in seven alcohol-dependent patientspresenting with this abnormality during alcoholization at twotimes: in acute withdrawal phase (under benzodiazepines) and15 days after beginning of withdrawal (free of any psychotropictreatment). Results: Our results show that this reversed rhythmof melatonin secretion as seen by the diurnal excretion of 6SM(6SM/creatinine ratio) persists during acute withdrawal in morethan half of the patients and is still present 15 days afterwithdrawal in three patients. Conclusion: It is remarkable thatthe inversion of the melatonin rhythms gets corrected in fourout of seven patients after withdrawal. But, the circadian disorganizationof melatonin secretion in three patients could underline a desynchronizationin some alcoholic patients and may indicate more widespreadcircadian temporal structure disturbances in these patients.     

Ethylene oxide does not extinguish the osteoinductive capacity of demineralized bone: A reappraisal in rats

We examined the influence of ethylene oxide (EO) and gamma irradiation on the osteoinductive capacity of demineralized bone. Demineralized bone powder prepared from Wistar rats was exposed to EO (55 °C or 40 °C) or gamma irradiation (25 KGy) or was preserved in ethanol. Sterilely-prepared bones served as controls. The powder was packed in a gelatin capsule and implanted for 6 weeks in muscles of 6-week-old female rats. Exposure of demineralized bone particles to EO 55 °C resulted in an almost complete loss of osteoinductivity. Irradiated bones lost about 40% of their osteoinductive capacity, while sterilization with EO at 40 °C resulted in only a slight alteration of the osteoinductivity, as assessed by the recovered weight ratio, calcium content, alkaline phosphatase activity measurements and histo-morphometry. Ethanol treatment had no influence on the new bone yield when compared to controls.

As EO exposure at 40 °C is a true sterilization procedure, it can be recommended in a clinical setting for its small effect on osteoinductive capacity as assessed experimentally in rats.     

Das traumatisch bedingte Kompartmentsyndrom des Unterschenkels

Zusammenfassung Um den Stellenwert der Sonographie als Methode der Diagnostik von Sp?tsch?den der Muskulatur nach operativ behandeltem Kompartmentsyndrom zu prüfen, wurden 27 Patienten (sechs Frauen, 21 M?nner) der Abteilung für Unfallchirurgie des Universit?tsklinikums Essen am ventralen Unterschenkel nach durchschnittlich 98 Monaten (43 bis 154 Monate) nach dem Trauma standardisiert untersucht und ein Vergleich mit der gesunden Gegenseite durchgeführt. Bei 15 Patienten war die Dermatofasziotomie wegen eines drohenden und bei zw?lf Patienten wegen eines manifesten Kompartmentsyndroms erfolgt. Im Vergleich zur gesunden Gegenseite konnte eine qualitative Gradeinteilung (0 bis 3) der Ver?nderungen erstellt werden, die das Ausma? der Echogenit?tsvermehrung sowie des Verlustes der muskeltypischen Textur wiedergibt. Grauwerthistogramme konnten die qualitative Einteilung best?tigen. Die Gruppe mit manifestem Kompartmentsyndrom zeigte ausschlie?lich deutliche und massive Ver?nderungen (Grad 2 und 3). Bei drohendem Kompartmentsyndrome fand sich zweimal Grad 2 und 13mal Grad 0 oder 1. Die sonographischen Ver?nderungen sind erkl?rbar durch die bekannten pathomorphologischen Zust?nde nach Kompartmentsyndrom der Muskulatur (Denervierung, Vernarbung). Die Sonographie eignet sich zur Beurteilung der Weichteile nach Kompartmentsyndrom. Die Ergebnisse unterstützen die Forderung nach einer frühzeitigen Fasziotomie bei drohendem Kompartmentsyndrom zur Pr?vention vor Muskel- und Nervensch?digungen.

---

Traumatic compartment syndrome of the lower limb: Significance of ultrasonography in evaluating long-term damage of muscle after dermatofasciotomy

To determine the significance of sonography in evaluating long-term damage of muscle surgically treated for compartment syndrome 27 patients of the Department for Trauma Surgery, University Clinic Essen, Germany, were examined on their anterior lower limb after an average of 98 (43 to 154) months after trauma. They had had a fasciotomy for imminent (n=15) or manifest (n=12) compartment syndrome. Comparing the healthy side a qualitative grading (0 to 3) of the changes could be introduced reflecting the extent of the increase in echogenicity and the loss of the typical muscle texture. Gray scale histograms confirmed the qualitative grading. Patients with manifest compartment syndrome showed severe changes (grade 2 and 3). In imminent compartment syndrome 2 patients with grade 2 and 13 patients with grade 0 or 1 were found. The sonographical changes can be explained by the known pathomorphological changes after compartment syndrome (denervation, scarification). Sonography is useful in the evaluation of soft tissue after compartment syndrome. The results underline the demands of early fasciotomy in imminent compartment syndrome for prevention of damage of muscle and nerve.

     

Comparative trial of sclerotherapy for hydroceles

We present a prospective single-blind trial of sclerotherapy for hydroceles with tetradecyl sulphate and rolitetracycline as sclerosants. Twenty-seven hydroceles were treated with tetradecyl sulphate and 28 with rolitetracycline. The median follow-up was 13 months. There were no statistically significant differences between the 2 drugs in respect of cure rate and complications. The overall cure rate for both drugs was 96%. Complications were rare and common to both drugs. Tetradecyl sulphate and rolitetracycline were found to be equally effective as sclerosants.     

Purification of Encephalitozoon Cultures Contaminated by Mycoplasmas by Murine Intraperitoneal Inoculation

Encephalitozoon species are strict intracellular microsporidia. Cocultures with eukaryotic cell lines can become accidently contaminated by mycoplasmas. We propose a decontamination protocol based on differential cell targeting after intraperitoneal inoculation in mice. Mycoplasma-free microsporidia were isolated from the brains and spleens of inoculated mice 24 h postinoculation by using the centrifugation shell vial system. Identification was confirmed by direct sequencing of PCR-amplified 16S rRNA.     

Metabotropic Glutamate Receptors Inhibiting Excitatory Synapses in the CA1 Area of Rat Hippocampus

In the CA1 region of hippocampal slices prepared from young adult rats, we studied the ability of several specific agonists of metabotropic glutamate receptors (mGluRs) to depress excitatory synaptic transmission at the CA3–CA1 pyramidal cell synapses. Three groups of mGluRs have been described: group 1 (mGluR1 and 5) receptors are positively coupled to phospholipase C whereas group 2 (mGluR2 and 3) and group 3 (mGluR4, 6, 7 and 8) receptors are negatively coupled to adenylate cyclase. We found that the broad-spectrum agonist (1 S ,3R)-1-aminocyclopentyl-1,3-dicarboxylate and the group 1-specific agonist ( R,S )-dihydroxyphenylglycine both reversibly inhibited evoked field excitatory postsynaptic potentials, indicating the involvement of group 1 mGluRs. ( R,S )-3,5-dihydroxyphenylglycine presumably inhibited transmission via a presynaptic mechanism, as whole-cell voltage-clamp recordings revealed that inhibition of the synaptic transmission was always accompanied with an increase in paired-pulse facilitation. Treatment with a specific blocker of mGluR1 receptors, the phenylglycine derivative ( S )-4-carboxyphenylglycine, was without effect on the (1 S ,3 R )-1-amino-cyclopentyl-1,3-dicarboxylate-induced depression of the field excitatory postsynaptic potentials, strongly suggesting that mGluR5 receptors are responsible for the (1 S ,3 R )-1-aminocyclopentyl-1,3-dicarboxylate effect. Two selective agonists of group 2 mGluRs, (2 S ,1' s ,2' s )-2-(2'-carboxycyclopropyl)glycine and 4-carboxy-3-hydroxyphenylglycine, were totally ineffective in blocking CA3-CA1-evoked synaptic transmission, excluding the involvement of mGluR2/3 subtypes at this developmental stage.     

Aneurysm of the abdominal aorta in an eighteen-month-old child

We report the case of an infected aneurysm of the abdominal aorta in a 18 month-old child, discovered by routine palpation of the abdomen during hospitalization for pneumonia. Ultrasonography and arteriography showed a 6 cm aneurysm of the abdominal aorta beginning distal to the renal arteries which occluded the right common Iliac artery. The aneurysm was treated by interposing a 6 mm Gore-Tex graft between the infrarenal aorta and the aortic bifurcation. Pathologic examination of the aneurysmal wall demonstrated a leukocytic Infiltrate and the presence of encapsulated Gram positive organisms. Arterial aneurysms are exceedingly rare in children. Their etiology is varied: infection, connective tissue disease, trauma, inflammatory arterial disease or other rare diseases such as tuberous sclerosis, neurofibromatosis, or Beçhet’s disease.     

Superinfecting mycobacteria home to established tuberculous granulomas

A central paradox of tuberculosis immunity is that reinfection and bacterial persistence occur despite vigorous host immune responses concentrated in granulomas, which are organized structures that form in response to infection. Prevailing models attribute reinfection and persistence to bacterial avoidance of host immunity via establishment of infection outside primary granulomas. Alternatively, persistence is attributed to a gradual bacterial adaptation to evolving host immune responses. We show here that superinfecting Mycobacterium marinum traffic rapidly into preexisting granulomas, including their caseous (necrotic) centers, through specific mycobacterium-directed and host cell-mediated processes, yet adapt quickly to persist long term therein. These findings demonstrate a failure of established granulomas, concentrated foci of activated macrophages and antigen-specific immune effector cells, to eradicate newly deposited mycobacteria not previously exposed to host responses.