Doppler echocardiography imaging of construction-induced regurgitation of technical heart valve prostheses]

The normal leakage flow in modern technical heart valve prostheses can be visualized by color-coded Doppler-echocardiography, provided that an adequate ultrasonic image quality can be achieved. Sometimes it may be difficult, however, to distinguish such a normal leakage flow from pathological regurgitation. We therefore mounted new specimens of five different types of prostheses (Bj?rk-Shiley monostrut, Medtronic-Hall, Omnicarbon, Saint Jude Medical, Duromedics) into an invitro model, where the leakage flows could directly be visualized as emerging water jets. When the system was completely filled, the jets could also be registered by two-dimensional Doppler-echocardiography. For each valve, characteristic patterns for the localization of the principal jets were found. Besides the relative broad central jet in the Medtronic-Hall valve, all other jets arose mainly at the ring. They were detected at the hinges or the basis of the larger struts, respectively, and with asymmetrical mono-disc valves at the side of the smaller opening. The length and the orientation of the jets were found to change significantly with minimal variations of the position of the closing discs. This variability could be confirmed, when in a separate model the overall leakage flows were repeatedly measured. For patient examinations it seems useful to refer mainly to the localization of the jet origins. The comparison with reference values of jet-dimensions in Doppler images will rarely enable the examiner to distinguish between normal and pathological jets.     

A "new" intraabdominal artery. The pedicled right gastroepiploic artery for myocardial revascularization.

The right gastroepiploic artery (GEA) was used as a pedicled conduit for direct coronary artery revascularization in 20 patients presenting with more or less exhausted saphenous vein resources. The early angiographic patency of the GEA conduit appears to be satisfactory when it is connected to the right coronary artery system. A distinct disadvantage of GEA grafting is the necessity to enter the abdominal cavity, which may lead to probably rare and as yet unrecognized morbidity. Future abdominal surgery may injure the GEA conduit unless its topographic relations to the prepyloric antrum, liver and diaphragm are properly recognized. The surgeon must then be prepared to encounter antegastric, retrogastric, antehepatic, transhepatic and retrohepatic routes of the redirected intraabdominal artery. The present paper addresses this problem. Preoperative angiography of the celiac trunk and superior mesenteric artery may be helpful in decision-making when a patient reports or records show that a graft has been harvested from the abdominal cavity.     

Galanin- and CGRP-like immunoreactivity coexist in rat spinal motoneurons.

We can report, that by the use of indirect immunofluorescence techniques, that rat spinal motoneurons contain galanin-like immunoreactivity (LI). Furthermore, that galanin and calcitonin gene-related peptide (CGRP)-LI coexist in a number of spinal motoneurons. Co-localization could be demonstrated as thoracic, lumbar as well as sacral spinal cord levels in individual neurons by studying adjacent sections each stained by one of the two antisera, as well as by double labelling experiments. Small neurons, within the gamma-motoneuron and interneuron size-range, were also positive for galanin-LI.     

Use of simple clinical signs to predict pneumonia in young Gambian children: the influence of malnutrition.

The current WHO recommendations for the case management of acute respiratory infections (ARI) in children aged 2 months to 5 years in developing countries use fast breathing (respiratory rate of > or = 50 per minute in children under 12 months and > or = 40 in children aged 12 months to 5 years) and lower chest wall indrawing to determine which child is likely to have pneumonia and should therefore receive antibiotics. We have evaluated these and other physical signs in 487 malnourished children and 255 well nourished children who presented with a cough or breathing difficulty. Pneumonia, defined as definite radiological pneumonia or probable radiological pneumonia associated with crackles on auscultation, was present in 145 (30%) of the malnourished children and 68 (26%) of the well nourished children. The respiratory rate predicted pneumonia equally well in the two groups, but to achieve an appropriate sensitivity and specificity the respiratory rate cut-off required in malnourished children was approximately 5 breaths per minute less than that in well nourished children. Intercostal indrawing was more common and lower chest wall indrawing was less common in the malnourished children, with or without pneumonia. These results suggest that fast breathing, as defined at present by WHO, and lower chest wall indrawing are not sufficiently sensistive as predictors of pneumonia in malnourished children. As the latter are a high-risk group, we should like to recommend that children with malnutrition who present with a cough, fast breathing or difficult breathing should be treated with antibiotics.     

A new monoclonal antibody against the GABA-protein conjugate shows immunoreactivity in sensory neurons of the rat.

A monoclonal antibody, 115AD5, was raised against GABA coupled to bovine serum albumin. The monoclonal antibody 115AD5 also reacted with other GABA-protein conjugates. The specificity of the monoclonal antibody was corroborated by enzyme-linked immunoassay, dot-immunobinding experiments and immunostaining of rat cerebellum sections. The monoclonal antibody 115AD5 could successfully be applied on Vibratome and cryostat sections using either indirect immunofluorescence or peroxidase techniques. In rat cerebellar cortex the monoclonal antibody 115AD5 gave an intense immunoreaction in stellate cells, in Golgi neurons, and in basket cells and their processes around Purkinje cell bodies. Purkinje cell dendrites showed GABA immunoreactivity while the cell bodies were non-reactive or only weakly reactive. There was labelling in some nuclei of Purkinje cells. GABA immunoreactivity was also found in dot-like structures in the granular layer. A large population of sensory neurons in rat thoracic and lumbar spinal dorsal root ganglia presented an intense immunoreactivity for the monoclonal antibody 115AD5. Nerve bundles immunoreactive for GABA were also seen in these ganglia. In the trigeminal ganglion, a major population of sensory neurons and some of their processes presented immunoreactivity for GABA. In the sensory nodose ganglion of the vagus nerve, many neuronal cell bodies and some fibres were immunoreactive for GABA. Ligation of the vagus nerve caudal to the ganglion resulted in an increased GABA immunoreactivity in neuronal somata of the ganglion, as well as in nerve fibres on the ganglionic side of the ligature. The present results suggest that in the rat, a population of sensory neurons in thoracic and lumbar spinal dorsal root ganglia, as well as in the trigeminal and nodose ganglia contain GABA. The presence of GABA immunoreactivity in these neurons raises the possibility of a neurotransmitter or modulator role.     

Prodromal frontal/executive dysfunction predicts incident dementia in Parkinson's disease.

To identify the cognitive characteristics predictive of incident dementia in Parkinson's disease (PD), we examined the baseline neuropsychological profiles of 18 initially non-demented patients with PD who met diagnostic criteria for dementia (PDD) at one-year follow-up. PDD participants' baseline neuropsychological test scores were compared to the baseline performance of 18 patients with PD who did not meet criteria for dementia at one-year follow-up (PDND) and 18 normal controls (NC). The three groups were matched on baseline demographic and disease variables. Relative to the PDND group, the incident PDD participants demonstrated significantly poorer performance on digits backward (Wechsler Memory Scale-Revised), word list learning and recognition (California Verbal Learning Test), and perseverative errors on the Wisconsin Card Sorting Test. Each of these baseline neuropsychological variables exhibited adequate diagnostic classification accuracy in predicting PDD and PDND group membership at follow-up. These results suggest that subtle frontal/executive dysfunction is evident during the immediate PDD prodrome and may be of prognostic value in identifying PD patients at risk for dementia. Accordingly, neuropsychological evaluation may facilitate early identification of PDD and thereby inform appropriate dispositional planning.     

Screening for Depression in Patients with Chronic Illness

Why should depression screening be conducted in chronically ill populations? Depression is a disabling illness and is very common among patients who have chronic illnesses. Despite its high prevalence in this patient population, depression often goes unrecognized. Having a plan for a population-based screening program for depression can not only identify patients who are at risk of depression, but can also help to foster early treatment and enhanced care for these patients. This article provides an overview of commonly-used depression screening tools and presents an example of how this might be carried out in a healthcare organization.     

Preoperative care of infants with nephroblastoma. The International Society of Pediatric Oncology 6 experience.

The International Society of Pediatric Oncology (SIOP) recommends preoperative treatment in the management of eligible patients with Wilms' tumor. Until 1980, children younger than 12 months of age (infants) at diagnosis had been excluded from the SIOP trials. SIOP 6, conducted from 1980 to 1987, was the first SIOP study to include infants older than 6 months of age. This retrospective analysis of 145 infants registered to SIOP 6 demonstrates that in infants older than 6 months and having favorable histology (FH), a two-drug preoperative chemotherapy (CT) regimen of 4 weeks significantly ameliorated stage distribution as determined at delayed surgery but did not affect a good outcome. However, the CT dose utilized in SIOP 6 resulted in an unacceptable toxicity in this age group, and SIOP 9, the new SIOP study of Wilms' tumor, recommends a reduced dose of CT in infants. Preoperative CT is not recommended in infants younger than 6 months of age. Specifically, the high incidence (29%) of mesoblastic nephroma in this age group does not justify such an approach. Histopathologic diagnosis should be obtained in these patients before any treatment.     

Long-term results after 'floppy' Nissen/Rossetti fundoplication for gastroesophageal reflux disease.

Eighty-two patients (median age, 51 years; range, 27-87 years) with refractory gastroesophageal reflux disease (GERD) underwent floppy Nissen/Rossetti fundoplication during the period 1980 to 1990. The median postoperative hospital stay was 5 days (3-16). Median follow-up was 72 months and included endoscopy and a clinical and a questionnaire assessment. Subjective symptoms of reflux were abolished in 98%, and 96% of the patients were satisfied with the results. Endoscopy showed healing of the esophagitis in 98%. There had been no disruption of the fundoplication. Twenty patients complained of gaseous distention and increased flatulence; only two of them had severe problems. Three patients were unable to belch. In conclusion, the floppy fundoplication has been an effective operation with no deaths, a low incidence of morbidity and adverse side effects, and without a tendency for late failure.