Bilobar apical pseudoaneurysm after left ventricular venting in a Marfan's patient.

A Marfan patient presented with a bilobar apical pseudoaneurysm after repeated surgery. These abnormalities were demonstrated by three-dimensional-echo, Doppler, and CT-reconstruction. The pseudoaneurysm was related to an apical venting procedure. In this case, a conservative approach was chosen, although in general, pseudoaneurysms form an indication for operative correction, because of the risk of rupture and acute tamponade.

[Wonder matter and assassin. The perception of the asbestos danger as a mirror of the time 1930-1990]. / Wonderstof en sluipmoordenaar. De perceptie van het Asbestgevaar als spiegel van de tijd 1930-1990.

In the seventies and eighties of the twentieth century the ideas of the dangers concerning the use of asbestos changed dramatically. The mineral, which had, more than half a century before been introduced in the Netherlands as a miraculous mineral, was completely banned from use. Asbestos became known as a 'silent killer' and 'the blue sand of death', and as a symbol of the hidden hazards of a deteriorating environment caused by unscrupulous companies and indolent authorities. Asbestos seems to fit perfectly into the ubiquitous hazards which Ulrich Beck defines in his concept of the 'risk society' as the dangerous side effects of industrial production. Yet the perception of the risk associated with asbestos depended more on socio-cultural characteristics than on scientifically risk assessments. In the first half of the twentieth century the use of asbestos was limited and therefore did not cause any concern. Economic crisis and war silenced the first alarming signals of asbestos related disease from foreign experts and a handful of Dutch physicians. The asbestos workers themselves were held responsible for their own health and safety. In the 1951 asbestosis became recognised as an industrial disease. Preventive measures with regard to the industrial use of asbestos were prescribed by law. Workers shared the responsibilities for a safe use with employers and authorities. However, during this period, all the attention was directed towards economic growth. Supervision by the labour inspection was scarce and workers and employers were not very interested in upholding the safety measures. Among asbestos workers the use of protective clothes and dust masks was generally seen as unmanly. In the sixties the foreign literature on the connection between the exposure to asbestos and the occurrence of lung cancer and mesothelioma became known among Dutch specialists. The results of these studies were confirmed by research among Dutch insulation workers. At the same time the trade unions rejected the idea of a shared responsibility and formulated the unilateral 'right to a safe working environment', with the implication that, in their view, all unhealthy and unsafe procedures should unconditionally be banned from the workshops, including the use of asbestos. Concerned civilians, environmental lobbyists, progressive political parties and concerned scientists transformed this idea into a 'right to a safe living environment', while mass media spread the message. Asbestos was pointed out as a threat to the public health, tracked down all of its hiding places and ultimately removed. The ban on asbestos was one of the results of democratisation and emancipation movement of the late sixties and seventies. The emancipation expressed itself in an increasing intolerance to risks brought about by powerful companies and bureaucratic authorities.

Results of a multicenter study of the retrievable Tulip Vena Cava Filter: early clinical experience.

PURPOSE: To evaluate clinically a new, retrievable vena caval filter in a multicenter study. METHODS: The Tulip filter is a stainless steel half-basket that is suitable for antegrade or retrograde insertion via an 8.5 Fr introducer sheath. The filter can be retrieved via the jugular approach using an 11 Fr coaxial retrieval system. Forty-eight filters were implanted via the femoral approach and 38 via the jugular approach in 83 patients. Follow-up examinations (plain films, colorcoded duplex sonography) were performed up to 3 years after filter insertion (mean 136 days) in 75 patients. Twenty-seven patients were screened by colorcoded duplex sonography for insertion site thrombosis. RESULTS: An appropriate filter position was achieved in all cases. Insertion problems occurred in 3 cases; these were not due to the filter design but to an imperfect prototype insertion mechanism that has now been modified (n = 2) or a manipulation error (n = 1). In 2 of these cases the filters were replaced percutaneously; 1 patient required venotomy for filter removal. No further complications due to filter insertion occurred. Two filters were used as temporary devices and were successfully removed after 6 and 11 days, respectively. There was 1 fatal recurrent pulmonary embolism (PE) and 2 non-fatal PE, 5 complete and 3 partial caval occlusions, and 3 caudal migrations of the filter. Insertion site venous thrombosis was not seen in the 27 patients monitored for this complication. CONCLUSION: Precise placement of the Tulip filter is feasible by either access route and the device appears mechanically stable. Further observations are needed to confirm that safe filter removal is practical up to 10 days after its insertion.

Value of exercise Doppler-echocardiography in patients with mitral stenosis.

The value of exercise Doppler-echocardiography was studied in 60 patients with mitral valve stenosis. Patients were divided in three groups. In patients with a mitral valve area of more than 1.4 cm2, maximal and mean diastolic gradient over the mitral valve increased from 13.2 +/- 3.6 to 18.4 +/- 5.4 and from 5.2 +/- 1.9 to 8.8 +/- 3.0 mmHg, respectively. In patients with a mitral valve area in between 1.0 and 1.4 cm2, maximal and mean gradient increased from 19.0 +/- 8.0 to 28.1 +/- 8.9 and from 8.8 +/- 4.9 to 14.8 +/- 6.4 mmHg, respectively. In patients with a mitral valve area of less than 1 cm2, the maximal gradient increased from 21.5 +/- 5.8 to 34.2 +/- 8.7 and mean gradient increased from 11.8 +/- 4.1 to 20.3 +/- 5.8 mmHg. Mean tricuspid regurgitation velocity increased from 2.9 +/- 0.5 m/s to 3.6 +/- 0.5 m/s, indicating increase in right ventricular to right atrial pressure difference from 34 mmHg to 52 mmHg. We conclude that exercise during the Doppler-echocardiographic evaluation provides additional information about the hemodynamic significance of mitral stenosis and can therefore be of value in decision making.

Use of technetium-99m sestamibi to determine the size of the myocardial area perfused by a coronary artery.

The value of the new radionuclide tracer, technetium-99m (Tc-99m) sestamibi, to demonstrate myocardial perfusion in areas supplied by specific coronary arteries was evaluated in patients injected with the agent during cardiac catheterization. Tc-99m sestamibi differs from thallium-201 in its physical characteristics (photon energy 140 keV), half-life (6 hours) and lack of significant redistribution, allowing its administration during an episode of chest pain or ischemia occurring outside the nuclear medicine laboratory with later imaging to visualize the distribution. In 13 patients Tc-99m sestamibi was administered intravenously during balloon-occlusion angioplasty. In 11 of 13 patients, defects of the single photon emission computed tomography images corresponded to the area made ischemic during angioplasty. In the remaining 2 patients, abundant collateral flow was present and no defects were seen. In a second study, 15 patients had Tc-99m sestamibi selectively injected into a coronary artery during angiography. Later imaging identified the area supplied by the artery injected. Tc-99m sestamibi imaging can detect perfusion defects associated with short episodes of ischemia, and the area supplied by the different coronary arteries.

Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery.

One hundred eighty of 1260 patients consecutively admitted to the hospital because of unstable angina pectoris had the typical ST-T segment changes suggestive of a critical stenosis in the proximal LAD. In 108 patients the ECG abnormalities were present at the time of admission. In the remaining 72 patients they developed shortly thereafter. The difference between these two groups was a longer duration of anginal complaints in the former (mean 2.3 days). Results of coronary angiography, performed a mean of 4.6 days after the last attack of chest pain, showed 50% or more narrowing in the proximal LAD in all patients. Thirty-three patients had complete occlusion of the LAD and 75 had collateral circulation to the LAD. Results of left ventricular angiography showed abnormal systolic left ventricular wall motion in 137 patients and normal systolic motion in the remaining 43 patients. The difference between these two groups was a shorter mean time interval between the last attack of chest pain and angiography in the former group (p less than 0.001). Twenty-four patients had only abnormal diastolic wall motion. Twenty-one patients had a small increase in the creatine kinase level at the time of admission. Fifteen patients (nine before and six during early revascularization) had an anterior wall myocardial infarction in the hospital; these patients had a patent but severely narrowed LAD and a low incidence of collateral circulation to the LAD.(ABSTRACT TRUNCATED AT 250 WORDS)

What do medical students know about in-hospital radiation hazards?

A questionnaire (eight multiple-choice questions) administered to 49 fourth-year medical students from the Limburg State University in the Netherlands shows that several misunderstandings, misconceptions, and erroneous beliefs exist in regard to in-hospital radiation hazards. The authors conclude that it is unlikely that ignorance about this subject is restricted to Dutch medical students.

Echography of the inferior vena cava is a simple and reliable tool for estimation of 'dry weight' in haemodialysis patients.

Using echography, the diameter of the inferior vena cava (IVC) and its decrease on deep inspiration (collapse index) were evaluated in haemodialysis patients. The diameter of the IVC was expressed as an index to the body surface area (VCD) in mm/m2. Non-linear regression analysis in predicting mean right atrial pressure by VCD (mm/m2) and collapse index revealed a good correlation (r = 0.92; P less than 0.001) in both measurements. These results indicate that the IVC indices can be used as a parameter for both high and low filling pressures. Over-hydration (mean right atrial pressure greater than 7 mmHg) was defined as a collapse index of less than 40% and a VCD of more than 11.5 mm/m2, and underhydration (mean right atrial pressure less than 3 mmHg) as a VCD of less than 8 mm/m2 and collapse index of above 75%. In 22 patients in whom dry weight was determined on clinical grounds, only six had a correct dry weight according to IVC indices. Reliability of IVC indices for estimation of body fluid status was proved by the fact that during haemodialysis with fluid removal, postdialysis underhydrated patients according to IVC indices showed a decrease of mean arterial pressure and stroke volume, and an increase of heart rate. No such changes were observed in postdialysis normovolaemic and hypervolaemic patients, according to the vena cava indices. Furthermore, blood volume in normo- and hypervolaemic patients decreased much less than in hypovolaemic patients, despite the same amount of ultrafiltration. Total blood volume (ml/m2) and VCD (mm/m2) correlated significantly (r = 0.61; P less than 0.001), whereas there was no significant correlation between collapse index and blood volume.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of thrombolytic therapy in unstable angina: clinical and angiographic results.

The incidence of intracoronary thrombus and the effects of thrombolytic therapy were studied in 41 patients with unstable angina. All patients underwent coronary angiography 2 to 69 h (mean 19) after their last attack of chest pain. Immediately after angiography, 21 patients received intracoronary streptokinase (250,000 IU in 45 min) and were retrospectively analyzed. Twenty patients received intravenous recombinant tissue-type plasminogen activator (rt-PA) (100 mg in 3 h) and were involved in a prospective study. Eleven of the 21 patients from the streptokinase group and 11 of the 20 patients from the rt-PA group showed a decrease in the severity of the coronary stenosis on repeat angiography 1 day later. A decrease in coronary obstruction was primarily observed in 10 of 13 patients with a complete stenosis and in 6 of 9 patients with a subtotal stenosis and markedly diminished coronary flow. Improvement in coronary anatomy was not determined by the clinical characteristics of the patients. Twenty-eight of the 41 patients had angiographic evidence of intracoronary thrombus formation before and 16 had such evidence after thrombolytic treatment. Nine patients developed a small increase in serum cardiac enzymes before or during treatment. Ischemic symptoms and the incidence of surgical or angioplastic intervention were not different in patients with or without a reduction in coronary artery stenosis after fibrinolytic therapy. These observations suggest a high incidence of coronary thrombosis in patients with unstable angina. The data do not permit assessment of the clinical therapeutic efficacy of thrombolytic therapy. Better risk stratification and placebo-controlled prospective studies are required to obtain information on the risk/benefit ratio of such therapy in unstable angina.

Transfection of the cloned human excision repair gene ERCC-1 to UV-sensitive CHO mutants only corrects the repair defect in complementation group-2 mutants.

The human DNA-excision repair gene ERCC-1 is cloned by its ability to correct the excision-repair defect of the ultraviolet light- and mitomycin-C-sensitive CHO mutant cell line 43-3B. This mutant is assigned to complementation group 2 of the excision-repair-deficient CHO mutants. In order to establish whether the correction by ERCC-1 is confined to CHO mutants of one complementation group, the cloned repair gene, present on cosmid 43-34, was transfected to representative cell lines of the 6 complementation groups that have been identified to date. Following transfection, mycophenolic acid was used to select for transferants expressing the dominant marker gene Ecogpt, also present on cosmid 43-34. Cotransfer of the ERCC-1 gene was shown by Southern blot analysis of DNA from pooled (500-2000 independent colonies) transformants of each mutant. UV survival and UV-induced UDS showed that only mutants belonging to complementation group 2 and no mutants of other groups were corrected by the ERCC-1 gene. This demonstrates that ERCC-1 does not provide an aspecific bypass of excision-repair defects in CHO mutants and supports the assumption that the complementation analysis is based on mutations in different repair genes.

Usefulness of the accelerated idioventricular rhythm as a marker for myocardial necrosis and reperfusion during thrombolytic therapy in acute myocardial infarction.

The value of the accelerated idioventricular rhythm (AIVR) as a marker for myocardial necrosis and/or reperfusion was prospectively studied in 87 patients admitted with persistent ischemic chest pain. All patients received streptokinase. Necrosis was diagnosed by new Q waves and an increase in plasma enzymes. Reperfusion was documented angiographically. Myocardial necrosis occurred in 72 patients and reperfusion in 70 patients, 58 of whom had myocardial necrosis. Of 27 patients with AIVR, 26 had both necrosis and reperfusion (p less than 0.001). AIVR started after a long coupling interval to the preceding sinus rhythm and was regular. Configuration depended on the reperfused infarct vessel. Reperfusion of the left anterior descending branch showed most configurations of AIVR and with the least QRS width. Reperfusion of the circumflex branch never had a left bundle branch block-like configuration. AIVR from reperfusion of the right coronary artery never had an inferior axis. AIVR occurring during persistent ischemic chest pain is a marker for both myocardial necrosis and reperfusion of the infarct vessel. AIVR starts with a long coupling interval and is regular. The QRS configuration may be useful for the noninvasive identification of the infarct vessel.

Central odontogenic fibroma. A case report.

A case of central odontogenic fibroma is reported. The clinical, radiological and pathological features are discussed. It is of particular interest because of its maxillary location and the severe external root resorption associated with the tumour.

Low dose ventriculography using a poor man's video image processor.

During revascularisation procedures repeated left ventriculography using iodine contrast materials may be an unnecessary burden on left ventricular performance. We therefore investigated in 10 patients the diagnostic quality of low dose ventriculography using a video image processor which enhanced digital left ventricular images. It is concluded that low dose ventriculography using up to 70% dilution of contrast can be diagnostic in 90% of all cases, depending of the side of interest.

Bedside digital subtraction angiography in critical care medicine.

A portable video image-processor unit used to evaluate bedside digital subtraction angiography yields sufficient information on the major arterial vessels and the heart, using standard x-ray equipment at fluoroscopic energy levels. This unit should contribute to the evaluation of the critically ill patient in the ICU.