Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation.

BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management. METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis. RESULTS: After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA2DS2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091). CONCLUSION: Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

Contrast-enhanced sonothrombolysis in acute ischemic stroke patients without intracranial large-vessel occlusion.

BACKGROUND: Contrast-enhanced sonothrombolysis (CEST) leads to a more rapid recanalization in acute ischemic stroke caused by intracranial large-vessel occlusion (LVO). Animal studies have shown that CEST also may be safe and efficient in treating the ischemic microcirculation in the absence of LVO. The exact mechanism behind this treatment effect is not known. We aimed to assess safety and efficacy of CEST in acute ischemic stroke patients included in the Norwegian Sonothrombolysis in Acute Stroke Study (NOR-SASS) without LVO on admission CT angiography (CTA). METHODS: NOR-SASS was a randomized controlled trial of CEST in ischemic stroke patients treated with intravenous thrombolysis within 4.5 hours after stroke onset. Patients were randomized to either CEST or sham CEST. In this study, patients were excluded if they had partial or total occlusion on admission CTA, ultrasound-resistant bone window, had received CEST with incorrect insonation as compared to stroke location on Magnetic resonance imaging (MRI), or were stroke mimics. RESULTS: Of the 183 patients included in NOR-SASS, a total of 83 (45.4%) patients matched the inclusion criteria, of which 40 received CEST and 43 sham CEST. There were no patients with symptomatic intracranial hemorrhage (sICH) in the CEST group. Rates of asymptomatic ICH, microbleeds, and mortality were not increased in the CEST group. Neurological improvement at 24 hours and functional outcome at 90 days were similar in both groups. CONCLUSION: CEST is safe in ischemic stroke patients without intracranial LVO. There were no differences in clinical outcomes between the treatment groups.

Speciation in a keystone plant genus is driven by elevation: a case study in New Guinean Ficus.

Much of the world's insect and plant biodiversity is found in tropical and subtropical 'hotspots', which often include long elevational gradients. These gradients may function as 'diversity pumps' and contribute to both regional and local species richness. Climactic conditions on such gradients often change rapidly along short vertical distances and may result in local adaptation and high levels of population genetic structure in plants and insects. We investigated the population genetic structure of two species of Ficus (Moraceae) along a continuously forested elevational gradient in Papua New Guinea. This speciose plant genus is pollinated by tiny, species-specific and highly coevolved chalcid wasps (Agaonidae) and represented by at least 73 species at our study gradient. We present results from two species of Ficus sampled from six elevations between 200 m and 2700 m a.s.l. (almost the entire elevational range of the genus) and 10 polymorphic microsatellite loci. These results show that strong barriers to gene flow exist between 1200 m and 1700 m a.s.l. Whereas lowland populations are panmictic across distances over 70 km, montane populations can be disjunct over 4 km, despite continuous forest cover. We suggest that the limited gene flow between populations of these two species of montane Ficus may be driven by environmental limitations on pollinator or seed dispersal in combination with local adaptation of Ficus populations. Such a mechanism may have wider implications for plant and pollinator speciation across long and continuously forested elevational gradients if generalist insect pollinators and vertebrate seed dispersers also form populations based on elevation.

Acute cerebral infarcts in multiple arterial territories associated with cardioembolism.

OBJECTIVES: It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism. MATERIALS AND METHODS: We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories. RESULTS: MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI. CONCLUSIONS: Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.

Prediction of underlying atrial fibrillation in patients with a cryptogenic stroke: results from the NOR-FIB Study.

BACKGROUND: Atrial fibrillation (AF) detection and treatment are key elements to reduce recurrence risk in cryptogenic stroke (CS) with underlying arrhythmia. The purpose of the present study was to assess the predictors of AF in CS and the utility of existing AF-predicting scores in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study. METHOD: The NOR-FIB study was an international prospective observational multicenter study designed to detect and quantify AF in CS and cryptogenic transient ischaemic attack (TIA) patients monitored by the insertable cardiac monitor (ICM), and to identify AF-predicting biomarkers. The utility of the following AF-predicting scores was tested: AS5F, Brown ESUS-AF, CHA2DS2-VASc, CHASE-LESS, HATCH, HAVOC, STAF and SURF. RESULTS: In univariate analyses increasing age, hypertension, left ventricle hypertrophy, dyslipidaemia, antiarrhythmic drugs usage, valvular heart disease, and neuroimaging findings of stroke due to intracranial vessel occlusions and previous ischemic lesions were associated with a higher likelihood of detected AF. In multivariate analysis, age was the only independent predictor of AF. All the AF-predicting scores showed significantly higher score levels for AF than non-AF patients. The STAF and the SURF scores provided the highest sensitivity and negative predictive values, while the AS5F and SURF reached an area under the receiver operating curve (AUC) > 0.7. CONCLUSION: Clinical risk scores may guide a personalized evaluation approach in CS patients. Increasing awareness of the usage of available AF-predicting scores may optimize the arrhythmia detection pathway in stroke units.

Atrial fibrillation in cryptogenic stroke and TIA patients in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results.

Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA2DS2-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension (p = 0.045) and dyslipidaemia (p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.

Water and energy link in the cities of the future - achieving net zero carbon and pollution emissions footprint.

This article discusses the link between water conservation, reclamation, reuse and energy use as related to the goal of achieving the net zero carbon emission footprint in future sustainable cities. It defines sustainable ecocities and outlines quantitatively steps towards the reduction of energy use due to water and used water flows, management and limits in linear and closed loop water/stormwater/wastewater management systems. The three phase water energy nexus diagram may have a minimum inflection point beyond which reduction of water demand may not result in a reduction of energy and carbon emissions. Hence, water conservation is the best alternative solution to water shortages and minimizing the carbon footprint. A marginal water/energy chart is developed and proposed to assist planners in developing future ecocities and retrofitting older communities to achieve sustainability.

The balance between sphingosine and sphingosine-1-phosphate is decisive for mast cell activation after Fc epsilon receptor I triggering.

Over the last few years, sphingolipids have been identified as potent second messenger molecules modulating cell growth and activation. A newly emerging facet to this class of lipids suggests a picture where the balance between two counterregulatory lipids (as shown in the particular example of ceramide and sphingosine-1-phosphate in T lymphocyte apoptosis) determines the cell fate by setting the stage for various protein signaling cascades. Here, we provide a further example of such a decisive balance composed of the two lipids sphingosine and sphingosine-1-phosphate that determines the allergic responsiveness of mast cells. High intracellular concentrations of sphingosine act as a potent inhibitor of the immunoglobulin (Ig)E plus antigen-mediated leukotriene synthesis and cytokine production by preventing activation of the mitogen-activated protein kinase pathway. In contrast, high intracellular levels of sphingosine-1-phosphate, also secreted by allergically stimulated mast cells, activate the mitogen-activated protein kinase pathway, resulting in hexosaminidase and leukotriene release, or in combination with ionomycin, give cytokine production. Equivalent high concentrations of sphingosine-1-phosphate are dominant over sphingosine as they counteract its inhibitory potential. Therefore, it might be inferred that sphingosine-kinase is pivotal to the activation of signaling cascades initiated at the Fc epsilon receptor I by modulating the balance of the counterregulatory lipids.

Fetal/neonatal allo-immune thrombocytopenia (FNAIT): past, present, and future.

UNLABELLED: We reviewed the English, American, and German literature for articles describing the prevalence, clinical presentation, outcome, therapeutic options, and screening possibilities for fetal/neonatal allo-immune thrombocytopenia (FNAIT), published between January 1950 and March 2007. The reported prevalence of FNAIT in human platelet antigen (HPA)-1a-negative women varies between 1/600 to 1/5000 live births among various populations. The typical picture is that of a neonate presenting with purpura minutes to hours after birth, born to a healthy mother with no history of infection or abnormal bleeding, after an uneventful pregnancy with a normal maternal platelet count. Thrombocytopenia in FNAIT can be severe, with intracranial hemorrhage occurring in 10% to 30% of severe FNAIT cases. Several types of neonatal treatment have been proposed, of which transfusion of HPA-compatible platelets is most effective. Antenatal management of FNAIT consists of weekly maternal intravenous immunoglobulin (IVIG) infusions, with or without oral steroid therapy. Serial fetal platelet transfusions can be provided in cases of failure of IVIG therapy, but the multiple cordocenteses that would be required to administer the platelets entail substantial risk. The possibilities for antenatal screening of first pregnancies are limited. Postnatal screening does not prevent neonatal morbidity and mortality. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize the many and varied causes of neonatal thrombocytopenia, explain that fetal/neonatal allo-immune thrombocytopenia (FNAIT) is a rare but devastating cause with potential high risk of recurrence, and recall the treatment options for FNAIT as well as their potential side effects.

Erythrocyte ageing in vivo and in vitro: structural aspects and implications for transfusion.

Erythrocyte transfusion is essential in conditions of large blood loss, of inadequate bone marrow production and of increased erythrocyte breakdown. The structural and biochemical changes that erythrocytes go through during storage, probably associated with the disappearance of up to 30% of the erythrocytes within 24 h after transfusion, are likely to contribute to the transfusion side effects: iron overload, erythrocyte adhesion to the endothelial surface with proinflammatory consequences, autoantibody formation, endothelial damage by released erythrocyte constituents, a hampered microcirculation and oxygen delivery. In vivo, senescent erythrocytes are marked for removal by binding of autologous immunoglobulin G to ageing antigens, which arise by changes in the conformation of the membrane domain of band 3. Also, vesicle formation has been described as an integral part of the erythrocyte ageing process. Comparable changes occur during erythrocyte storage. This review describes the current state of knowledge of the mechanism of erythrocyte ageing in vivo, ageing-related changes occurring during erythrocyte storage in blood bank conditions and their possible relation with the transfusion side effects. In view of the key position of band 3 in the maintenance of erythrocyte structure and function, elucidation of the pathways that control posttranslational modification of band 3 during storage may lead to new approaches towards maintaining ATP concentration and cellular integrity. This review concludes with the challenge to further explore the underlying processes of erythrocyte ageing in order to provide physiologically relevant tools for assessing and predicting erythrocyte homeostasis in vitro and in vivo and thereby to contribute to the development of rational transfusion protocols for various patient categories.

The effect of ethylene oxide sterilization on electrospun vascular grafts made from biodegradable polyesters.

The study describes the detailed examination of the effect of ethylene oxide sterilization on electrospun scaffolds constructed from biodegradable polyesters. Different fibrous layers fabricated from polycaprolactone (PCL) and a copolymer consisting of polylactide and polycaprolactone (PLCL) were investigated for the determination of their mechanical properties, degradation rates and interaction with fibroblasts. It was discovered that the sterilization procedure influenced the mechanical properties of the electrospun PLCL copolymer scaffold to the greatest extent. No effect of ethylene oxide sterilization on degradation behavior was observed. However, a delayed fibroblast proliferation rate was noticed with concern to the ethylene oxide sterilized samples compared to the ethanol sterilization of the materials.

Red cell transfusion in medicine: future challenges.

Many side-effects of red blood cell transfusion have been described. They include iron-overload, as well as allo- and autoantibody formation against red cells. During storage, erythrocytes undergo complex structural and biochemical changes. It has been suggested that accelerated and/or aberrant forms of the physiological erythrocyte aging process underlie the red cell storage lesion. This storage lesion may contribute to side-effects of transfusion as endothelial damage by release of internal erythrocyte constituents, (pro)inflammatory consequences, hampered microcirculation and oxygen delivery. Understanding the process that determines the fate of red blood cells after transfusion may contribute to the prevention of side-effects after red blood cell transfusion. This should be the focus of research on red blood cell transfusion in clinical transfusion medicine.

Diffuse pollution abatement--a key component in the integrated effort towards sustainable urban basins.

Water bodies are highly stressed by overdrafts of water for many purposes upstream and in the cities, and effluent domination and excessive point and diffuse pollution downstream. Pollution is also caused by the urban landscape which prefers impervious rather than porous surfaces; fast-conveyance infrastructure rather than "softer" approaches like ponds and vegetation; and stream channelization instead of natural stream courses, buffers and floodplains, and development in the floodplains. In future, the comprehensive and complex problems of urban pollution must be solved within the framework of the total hydrological cycle concept. This provides a new impetus to diffuse pollution management in urban areas. The best management practices that have been developed in the past could become key components of the new urban total hydrological cycle paradigm for solving the water shortage and pollution problems in an integrated manner, and making the urban systems hydrologically and ecologically sustainable. The paradigm will include landscape changes (less imperviousness, more green space used as buffers and groundwater recharge) as well application of the best management practices that provide water conservation, storage and reuse.

Probabilistic evaluation of ammonia toxicity in Milwaukee's Outer Harbor.

Water-quality models that are simple yet sound and reliable and that correspond to water-quality criteria that include magnitude, frequency, and duration components are needed. Monte Carlo models are developed on the basis of available flow and water-quality data and a deterministic water-quality model appropriate for the problem at hand and the data available. Monte Carlo models yield time series and probability distributions of constituents of interest in conformance with water-quality criteria. The application of a Monte Carlo model to the probabilistic evaluation of ammonia toxicity in Milwaukee's Outer Harbor is presented here. Under typical operating conditions for the Jones Island Wastewater Treatment Plant, ammonia toxicity was found to not be a problem for the Outer Harbor. The Monte Carlo model then was used to determine effluent limits that would meet the ammonia toxicity criteria.

Fatty acid profile in erythrocyte membranes and plasma phospholipids affects significantly the extent of inflammatory response to coronary stent implantation.

In coronary heart disease, the treatment of significant stenosis by percutaneous coronary intervention (PCI) with stent implantation elicits local and systemic inflammatory responses. This study was aimed at evaluation of the dynamics of inflammatory response and elucidation of the relationship between the fatty acid profile of red blood cell (RBC) membranes or plasma phospholipids and inflammation after PCI. High-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), serum amyloid A (SAA), malondialdehyde (MDA) and the fatty acid profiles were determined in patients with advanced coronary artery disease undergoing PCI before, 24 h and 48 h after drug-eluting stent implantation (n=36). Patients after PCI exhibited a significant increase in studied markers (hsCRP, IL-6, SAA, MDA). Many significant associations were found between the increase of IL-6, resp. SAA and the amounts of n-6 polyunsaturated fatty acids (namely linoleic, dihomo-gamma-linolenic, docosatetraenoic and docosapentaenoic acid), resp. saturated fatty acids (pentadecanoic, stearic, nonadecanoic) in erythrocyte membranes. The magnitude of the inflammatory response to PCI is related to erythrocyte membrane fatty acid profile, which seems to be a better potential predictor of elevation of inflammatory markers after PCI than plasma phospholipids.

[Incidental undifferentiated carcinoma of the prostate: A case with unusual diagnosis]. / Inzidentelles undifferenziertes Karzinom der Prostata : Ein Fall mit überraschender Wendung.

A 69-year-old man presented with an incidental undifferentiated carcinoma of the prostate. Ten years ago the patient had clinical stage I seminoma of the right testis with adjuvant radiotherapy. Follow-up care was without pathological findings. Staging examinations did not show metastatic disease. After radical prostatectomy with pelvic lymphadenectomy, the histological examination revealed a metastatic seminoma in the prostate. Therefore, the diagnosis was a late relapse in an extremely rare location. So far only four other reports describe testicular seminoma with metastases to the prostate.

Pharmacokinetics and pharmacogenetics of capecitabine and its metabolites following replicate administration of two 500 mg tablet formulations.

PURPOSE: To describe concentration versus time profiles of capecitabine and its metabolites 5'-DFUR, 5'-DFCR and 5-FU, depending on tablet formulation and on frequent and/or relevant genetic polymorphisms of cytidine deaminase, dihydropyrimidine dehydrogenase, thymidylate synthase and methylenetetrahydrofolate reductase (MTHFR). METHODS: In 46 cancer patients on chronic capecitabine treatment, who voluntarily participated in the study, individual therapeutic doses were replaced on four consecutive mornings by the study medication. The appropriate number of 500 mg test (T) or reference (R) capecitabine tablets was given in randomly allocated sequences TRTR or RTRT (replicate design). Average bioavailability was assessed by ANOVA. RESULTS: Thirty female and 16 male patients suffering from gastrointestinal or breast cancer (mean age 53.4 years; mean dose 1739 mg) were included. The T/R ratios for AUC0-t(last) and C max were 96.7 % (98 % CI 90.7-103.2 %) and 87.2 % (98 % CI 74.9-101.5 %), respectively. Within-subject variability for AUC0-t(last) and C max (coefficient of variation for R) was 16.5 and 30.2 %, respectively. Similar results were seen for all metabolites. No serious adverse events occurred. For the MTHFR C677T (rs1801133) genotype, an increasing number of 677C alleles showed borderline correlation with an increasing elimination half-life of capecitabine (p = 0.043). CONCLUSIONS: The extent of absorption was similar for T and R, but the rate of absorption was slightly lower for T. While such differences are not considered as clinically relevant, formal bioequivalence criteria were missed. A possible, probably indirect role of the MTHFR genotype in pharmacokinetics of capecitabine and/or 5-FU should be investigated in further studies.

The size distribution of conspecific populations: the peoples of New Guinea.

The size distribution of the language populations in New Guinea, which represent over 15% of the world's languages, is analysed using models analogous to the resource division models of species abundance distribution in ecological communities. A model distribution of resource segments reflecting population size is created by repeated selection of an existing resource segment and its division into two. We found that any dependency of the selection probability on the size of the segment generated negatively skewed abundance distributions after log transformation. Asymmetric segment division further exacerbated the negative skewness. Size-independent selection produced lognormal abundance distributions, irrespective of the segment division method. Size-dependent selection and asymmetric division were deemed reasonable assumptions since large language populations are more likely to generate isolates, which develop into new populations, than small ones, and these isolates are likely to be small relative to the progenitor population. A negatively skewed distribution of the log-transformed population sizes was therefore expected. However, the observed distributions were lognormal, scale invariant for areas containing between 100 and over 1000 language populations. The dynamics of language differentiation, as reflected by the models, may therefore be unimportant relative to the effect of variable growth rates among populations. All lognormal distributions from resource division models had a higher variance than the observed one, where half of the 1053 populations had between 350 and 3000 individuals. The possible mechanisms maintaining such a low variance around a modal population size of 1000 are discussed.

Clozapine in the treatment of schizophrenic patients: an international multicenter trial.

One hundred twenty schizophrenic patients were treated with clozapine for two months in accordance with a standard trial protocol at ten research centers in the USSR, Czechoslovakia, Hungary, Poland, Bulgaria, and in the GDR. The daily dose ranged from 50 mg to 550 mg (mean: 272.1 mg for responders; 298 mg for nonresponders). In 94 patients (78%) the disease was clearly progressive; in 57 (47.5%) it was continuous; in 63 (52.5%) it was episodic. Before the start of clozapine treatment, 95 of the patients (79%) had been receiving other neuroleptics. There was a positive therapeutic response in 80% of the responding patients. The effect of clozapine was closely related to the dominant syndrome structure of the psychosis: a positive response was noted in 89% of patients with delusional, hallucinatory-delusional, and catatonic states and in 60% of patients with affective-delusional syndromes. Moderate side effects were noted in 87 patients (73%). The incidence of side effects reached a peak during the first four weeks of treatment and then declined despite maintenance of or even an increase in the daily clozapine dose. Hematological changes (moderate leukocytosis and thrombocytopenia) were noted in eight patients (6.7%).

An unusual presentation and way to diagnose hepatocellular carcinoma.

A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with acute progression of dyspnoea, productive cough, fever, elevated central venous pressure, oedema and liver enzyme abnormalities. Pneumonia with secondary right-sided congestive heart failure was considered. Additional abdominal ultrasound examination confirmed by a CT scan showed a mass in the inferior vena cava (VCI) extending into the right atrium. The central liver location and impaired haemostasis rendered liver biopsy impossible. An alternative approach was discussed and guided by two-dimensional transoesophageal electrocardiography accessing the right internal jugular vein, biopsies were taken from the atrial mass with histology suggesting the presence of a hepatocellular carcinoma as the cause of acute dyspnoea.