Takotsubo syndrome in patients with myasthenia gravis: a systematic review of previously reported cases.

BACKGROUND: Myasthenia gravis associated takotsubo syndrome is a rare condition. This study aimed to explore its typical presentation, investigations and treatment through a systematic review of previously reported cases. METHODS: Databases and reference lists of the selected articles were searched for case reports on Myasthenia gravis associated takotsubo syndrome. CARE guidelines were used for the quality assessment of the selected articles. RESULTS: Sixteen cases were selected out of 580 search results. Western Pacific, American and European regions contributed to 88% of the cases. Females were most affected (81%). Features of both myasthenia gravis and takotsubo syndrome were the common clinical presentations. All cases had a myasthenic crisis. Half of the cases had no prior diagnosis of myasthenia gravis. Pyridostigmine and prednisolone were useful for myasthenia gravis while dobutamine was most commonly used for takotsubo syndrome. All cases survived except four (25%). CONCLUSIONS: Myasthenia gravis associated takotsubo syndrome via a myasthenic crisis is rare but life-threatening. Therefore, predisposition due to emotional and physical triggers needs to be avoided for its prevention. The rare entity should be suspected even in patients without a prior diagnosis of Myasthenia gravis.

Aortic dissecting aneurysm associated with systemic arterial hypertension in a cat.

INTRODUCTION: Aortic dissection is characterized by a tear in the aortic wall resulting in blood from the aortic lumen penetrating into the media, which causes dissection. When aortic dissection does not cause rupture, it provokes localized dilation of the aorta or aneurism, also called dissecting aortic aneurism (DAA). This case report describes a DAA in a cat associated with systemic arterial hypertension (SAHT). A 10-year-old male Domestic shorthair cat was presented for cardiac evaluation. Anamnestic clinical complaints were a syncope associated with paraparesis and weak femoral pules. Cardiomegaly had been found radiographically, and cardiogenic arterial thromboembolism had been suspected. Upon presentation physical abnormalities were tachycardia and a heart murmur. Measurement of systolic systemic arterial blood pressure (SABP) revealed severe SAHT. Echocardiographic images showed severe DAA, and marked aortic valve insufficiency. Palliative antihypertensive treatment resulted in fast clinical improvement and significant decrease in blood pressure. Four months later, acute severe respiratory distress due to cardiogenic pulmonary edema led to the cat's euthanasia. In human medicine, DAA is a well-reported complication of SAHT. This is the second case of DAA with congestive heart failure reported in a hypertensive cat.

Atrial cardiomyopathy in an adult Labrador retriever dog.

INTRODUCTION: A 7-year-old castrated male Labrador retriever was examined for a 10-day history of weakness and syncope. Physical examination revealed bradycardia and a grade III/VI left apical systolic heart murmur. Electrocardiography demonstrated bradycardia, absence of P waves and an atrio-ventricular nodal escape rhythm. Echocardiography revealed marked biatrial enlargement. Thoracic radiographs showed no evidence of pulmonary edema. Routine plasma biochemistry and electrolytes, basal serum cortisol, total thyroxin concentration, and complete blood count were within normal limits. Serum cardiac troponin I concentration was moderately increased. Serological examinations for antibodies against vector-borne diseases were negative. A pacemaker was implanted one month after the initial presentation due to worsening of the dog's clinical condition despite medical treatment. The dog remained asymptomatic for 18 months but was then re-presented with a gastric dilatation volvulus and subsequently euthanized. Necropsy and histology of the heart yielded a diagnosis of atrial cardiomyopathy.

Antemortem diagnosis of a left auricular appendage herniation through a partial pericardial defect in a dog with degenerative mitral valve disease.

INTRODUCTION: A 14-year-old neutered male crossbreed dog was presented for weakness, cough and weight loss. Cardiac auscultation revealed tachycardia, arrhythmia and a grade V/VI left apical systolic heart murmur. Thoracic radiographs showed a large homogeneous soft tissue opacity in close contact with the cardiac silhouette in the left cranioventral mediastinum. Cardiac evaluation showed atrial fibrillation, degenerative mitral valve disease and a dilated left auricular appendage outside the pericardium consistent with herniation through a partial pericardial defect. Seven months after diagnosis, an atrial septal defect secondary to acquired atrial septal rupture was identified. The dog was euthanized thirteen months after initial presentation because of unresponsive clinical signs of congestive heart failure.

Tachycardia-induced cardiomyopathy in a cat.

A 10-year-old male castrated Domestic Shorthair cat was evaluated for an asymptomatic tachyarrhythmia noted two weeks prior. Electrocardiography revealed a normal sinus rhythm with atrial premature complexes and paroxysms of supraventricular tachycardia with a heart rate between 300 and 400 min-1. Echocardiography was unremarkable, and concentrations of circulating cardiac troponin I, T4, and blood taurine were within reference ranges. The cat was treated with sotalol (2.1 mg/kg q12h, PO) but the arrhythmia was insufficiently controlled as determined during several re-examinations within a two-year time period. Twenty four months after initial presentation atrial fibrillation with fast ventricular response rate (200 to 300 min-1) was diagnosed, along with severe eccentric chamber remodeling and systolic dysfunction. The cat developed congestive heart failure and cardiogenic shock and was euthanized nearly 27 months after the first exam. Gross and histopathologic findings ruled out commonly seen types of primary myocardial disease in cats. The persistent nature of the tachyarrhythmia, the progressive structural and functional cardiac changes, and comparative gross and histopathologic post-mortem findings are consistent with the diagnosis of tachycardia-induced cardiomyopathy.

Cardiodoron® bei funktionellen Herz-Kreislauf-Beschwerden und Blutdruckauffälligkeiten: Eine Sekundäranalyse einer prospektiven Beobachtungsstudie.

Hintergrund: Bis zu 40% aller Herzpatienten können den funktionellen Herz-Kreislauf-Beschwerden (FHKB) zugeordnet werden. Dieses Krankheitsbild ist häufig mit Schlafstörungen und Blutdruckauffälligkeiten vergesellschaftet. Somit war es von Interesse, diesen Zusammenhang im Rahmen einer nichtinterventionellen Studie mit Cardiodoron® - ein Arzneimittel, das Störungen der vegetativen Rhythmik entgegenwirkt - näher zu beleuchten. Patienten und Methoden: 92 Ärzte dokumentierten insgesamt 501 Patienten mit FHKB und/oder Schlafstörungen, die 3 bis 6 Monate Cardiodoron® (Dilution) erhielten. Die Subgruppe der 454 Patienten mit FHKB bzw. 269 Patienten mit vollständigen Werten wurde hinsichtlich kardiologisch relevanter Parameter genauer betrachtet und steht im Mittelpunkt dieser Publikation. Ergebnisse: Die ärztlicherseits bewertete Ausprägung der FHKB reduzierte sich um 68% von 1,9 auf 0,6 Punkte. Der Symptomsummenscore aus 30 Einzelsymptomen ging um 61% von 23,6 auf 9,1 Punkte zurück. Blutdruckauffälligkeiten waren mit 1,6 zu 0,7 Punkten rückläufig. Weiterhin beurteilten die Patienten ihr Befinden mittels der Beschwerden-Liste nach von Zerssen, deren Gesamtwert sich um 58% von 24,0 auf 10,2 Punkte verminderte. Schlussfolgerung: Cardiodoron® ist ein gut verträgliches Arzneimittel der anthroposophischen Therapierichtung mit positivem Effekt bei Patienten mit FHKB, insbesondere bei Blutdruckauffälligkeiten.

[CME: Mechanical Assist Devices in Cardiopulmonary Resuscitation]. / CME: Mechanische Reanimationshilfe bei Herz-Kreislauf-Stillstand CME-Fragen.

CME: Mechanical Assist Devices in Cardiopulmonary Resuscitation Abstract. Early high-quality cardiopulmonary resuscitation in the event of a cardiac arrest is the most effective measure to improve the outcome. With the aim of improving the quality of resuscitation and replacing the need of manual compression, various mechanical assist devices have been developed and are used in the clinical practice. When should they be used, whether do they lead to better outcomes and what injuries are they associated with? These questions have been examined in several studies and the following review will provide an overview.

[CME/Answers: Mechanical Assist Devices in Cardiopulmonary Resuscitation]. / CME/Antworten: Mechanische Reanimationshilfe bei Herz-Kreislauf-Stillstand.

CME/Answers: Mechanical Assist Devices in Cardiopulmonary Resuscitation Abstract. Early high-quality cardiopulmonary resuscitation in the event of a cardiac arrest is the most effective measure to improve the outcome. With the aim of improving the quality of resuscitation and replacing the need of manual compression, various mechanical assist devices have been developed and are used in the clinical practice. When should they be used, whether do they lead to better outcomes and what injuries are they associated with? These questions have been examined in several studies and the following review will provide an overview.

Opening the closed heart: affect-focused clinical work with the victims of early trauma.

This paper begins with the understanding that early trauma leads to powerful dissociative defenses which injure the capacity to feel. It further explores ways to restore this capacity through body-centred attention to affect-in-the-moment in the psychoanalytic situation. Using the author's personal experience while in analysis as well as a case of severe early trauma, he demonstrates the consciousness-killing effect of primitive defenses and shows how body-sensitive techniques hold the promise of restoring the patient's sense of aliveness and hence, opening the unconscious to those affect-images that are the building blocks of the human imagination. A final section focuses on the neglect of feeling in Jungian psychology and suggests that the "creation of consciousness" which Jung described as his personal myth, is quintessentially a process of emotional transformation - of bringing unconscious suffering into consciousness - as feelings.

Cet article commence avec l'acceptation que le traumatisme précoce produit de puissantes défenses dissociatives qui portent atteinte à la capacité à ressentir. L'article explore ensuite des manières de restaurer cette capacité par l'utilisation d'une attention centrée sur le corps et sur l'affect-dans-le-moment-présent dans la situation psychanalytique. En s'appuyant sur son expérience personnelle durant l'analyse ainsi que sur un cas de traumatisme précoce sévère, l'auteur montre que les défenses primitives ont pour effet de tuer la conscience. Il montre aussi comment des techniques sensibles au corps contiennent la promesse de la restauration du sens de la vitalité du patient, et ainsi d'ouvrir l'inconscient aux images chargées d'affect qui sont les éléments constitutifs de l'imagination humaine. La dernière partie de l'article montre la négligence en ce qui concerne le sentiment dans la psychologie Jungienne et suggère que la « création de la conscience ¼ que Jung décrit comme étant son mythe personnel, est en quintessence un processus de transformation émotionnelle: d'amener la souffrance inconsciente à la conscience, en tant que sentiments.

El presente trabajo comienza con la comprensión de que el trauma temprano conduce a poderosas defensas disociativas las cuales dañan la capacidad de sentir. Explora formas de restaurar esta capacidad a través de una atención-centrada-en-el-cuerpo al afecto-en-el-momento, en la situación psicoanalítica. A partir, de la experiencia personal del autor durante análisis y también con un caso de trauma temprano severo, demuestra el efecto asesino de la conciencia de las defensas primitivas y muestra cómo técnicas corporales-sensitivas sostienen la promesa de restaurar en el/la paciente su sentido de vitalidad, y por lo tanto, posibilitan la apertura inconsciente a aquellas imágenes-afectivas que son las piedras fundacionales de la imaginación humana. Una sección final se focaliza en la desconsideración del sentimiento en la psicología Junguiana y sugiere que la 'creación de la consciencia', la cual Jung describe como su mito personal es quinta-esencialmente un proceso de transformación emocional, de traer el sufrimiento inconsciente a la consciencia, como sentimientos.

The image and the meaning of the Chinese character for 'enlightenment'.

This article explores the significance of the image of the Chinese character for 'enlightenment'. The oracle bone script form for 'enlightenment' is comprised of the symbol for the 'true self' and the symbol for the 'heart'. In Chinese Taoist philosophy, the true self is close to Tao, a concept akin to that of the self in Analytical Psychology. The combination of the 'self' meeting with the 'heart' conveys both the aspect of inspiration and of profound meaning. The paper is composed of three parts in order to facilitate the analysis and interpretation of this Chinese character: 1) an exploration of the image and meaning of the character; 2) an exploration of the link between the self and enlightenment; and 3) reflections on the relationship between insight and enlightenment. The image of this Chinese character contains not only what enlightenment is, but also the way to enlightenment and the meaning of the way.

[Detection of adverse events using IHI Global Trigger Tool during the adoption of a risk management system: A retrospective study over three years at a department for cardiovascular surgery in Vienna]. / Detektion unerwünschter Ereignisse mittels IHI Global Trigger Tool im Kontext der Einführung eines Risikomanagement-Systems: Eine retrospektive Studie über einen Zeitraum von 3 Jahren an der Herz- und Gefäßchirurgischen Abteilung eines Wiener Schwerpunktkrankenhauses.

BACKGROUND: Several studies point in the direction that the Global Trigger Tool for Measuring Adverse Events (GTT) published by the Institute for Healthcare Improvement (IHI) is an appropriate method to detect adverse events with high specificity, sufficient sensitivity and adequate interrater and intrarater reliability. After passing a certain training period, rating teams in healthcare institutions can successfully detect and reliably compare adverse event rates on local and national levels. To date there exist no published relevant data specifically for departments of cardiovascular surgery. METHODS: In this single-center, retrospective study adverse event rates were detected using GTT for a department of cardiovascular surgery in a Viennese hospital. Having begun to establish a risk management system in the year 2008, 120 case histories were rated by a trained team for the years 2009 and 2012 each (240 in total). RESULTS: From 2009 to 2012 the detection rate for adverse events improved significantly from 21.1 to 42.8 events per 1,000 patient days. This change was in agreement with an improvement in the detection rate of adverse events per 100 hospital admissions (from 43.7 to 80.0) as well as an improvement in the detection rate of the proportion of patients suffering from adverse events (from 24.4 % to 42.5 %). CONCLUSION: In the course of the introduction and continuous optimization of a risk management system, the detection rate of adverse events, as measured with GTT, could be brought up to international standards. Thus, the utility of GTT as a possible instrument to help increase patient safety and improve quality could also be established at a department of cardiovascular surgery.

Evaluation of anticonvulsant and analgesic activity of new hybrid compounds derived from N-phenyl-2-(2,5-dioxopyrrolidin-1-yl)-propanamides and -butanamides.

Epilepsy is a chronic neurological disorder that is associated with various types of recurrent seizures, which are drug-resistant in about one third of patients. Moreover, anticonvulsant drugs are used to treat a wide range of non-epileptic conditions, including chronic pain. Here, we investigated the anticonvulsant activity of six new hybrid compounds based on the pyrrolidine-2,5-dione scaffold in the 6 Hz corneal stimulation test with 44 mA stimulus intensity in mice, which is the model of pharmacoresistant seizures. We demonstrated that two molecules, DK-10 (11) and DK-14 (14) show higher anticonvulsant activity and similar safety profile in comparison with valproic acid and much higher in comparison with levetiracetam in the aforementioned test. The second aim of this study was to examine analgesic activity of these compounds. For this purpose, the hot plate test, the formalin test, and the oxaliplatin-induced peripheral neuropathy model were performed. Among tested agents DK-11 (12) revealed prominent antinociceptive activity at non-sedative doses in the second (inflammatory) phase of the formalin test, which is the model of tonic pain and antiallodynic activity in the oxaliplatin-induced neuropathic pain, the model of painful chemotherapy-induced peripheral neuropathy. No cytotoxic effect on hepatoma cells was observed. Compound DK-10 (11) had high affinity for voltage-gated sodium channels, whereas compound DK-11 (12) showed weak binding toward sodium and calcium voltage-gated channels and the NMDA receptor. As a result, hybrid compounds reported herein seem to be very promising broad spectrum anticonvulsant molecules with collateral analgesic activity.

[The Old-Age Heart]. / Das Herz im Alter.

The Old-Age Heart Abstract. Knowledge of cardiovascular changes in old age and their therapeutic options is important. Old age can lead to hypertrophy of the left ventricle, diastolic dysfunction, heart valve changes and pulmonary hypertension. Patients often develop arterial hypertension. Valvular changes are common in people over 100 years of age (aortic stenosis and mitral insufficiency). The risk of coronary heart disease is 35 % for men and 24 % for women. In old age, sinus node dysfunction and atrial fibrillation are common. 25 % of all strokes are cardiac embolisms in atrial fibrillation. Cardiac interventions in the elderly are increasingly frequent and include coronary catheter revascularization or valve interventions (percutaneous aortic valve replacement or MitraClip). Optimal therapy in old age includes not only cardiovascular interventions also include drugs and a lifestyle modification and mainly serves to improve the quality of life.

[Diving Accidents in Lakes - a Retrospective Study of a Level-1 Emergency Centre in Switzerland]. / See-Tauchunfälle ­ eine retrospektive Studie eines Level-1-Notfallzentrums der Schweiz.

Diving Accidents in Lakes - a Retrospective Study of a Level-1 Emergency Centre in Switzerland Abstract. Switzerland is a country in the middle of Europe without access to an open sea. Here one does not assume a noteworthy number of diving accidents. However, this study shows a large number and attempts to explore the main risks of diving accidents. The data from 2001 to 2016 of patients had been collected und retrospectively evaluated using the electronic database of the emergency center of the university hospital in Bern, Switzerland. Barotrauma of the ear (69.0 %), decompression accidents (20.7 %) as well as cardiovascular complications (13.8 %) appeared quite frequently during scuba diving in Switzerland. In contrast, otitis occurred only at a very low percentage (3.5 %). The risk of diving accidents is clearly underestimated. Preventative measures should include more emphasis on the vertical diving profile with increasing diving depths and on the hazards of cardiovascular diseases with increasing age.

The influence of cardiac triggering time and an optimization strategy for improved cardiac MR spectroscopy.

PURPOSE: To study how cardiac motion affects the spectral quality in cardiac MR spectroscopy and to establish an optimization strategy for the cardiac triggering time for improved quality and success rate of cardiac MRS. METHOD: Water spectra were acquired while the cardiac triggering time was varied over the cardiac cycle, and five different spectral quality parameters were studied (frequency, phase, linewidth, amplitude and noise). Furthermore, three different optimization strategies for the cardiac triggering time were tested, and finally, a comparison was made between water suppressed lipid spectra acquired in systole and diastole. RESULTS: The cardiac triggering time had a high impact on the spectral quality, especially on the mean signal amplitude and the standard deviation of the signal amplitude, phase and linewidth. Generally, the highest spectral quality was observed for spectra acquired in mid to end systole, at approximately 23% of the cardiac cycle. The exact optimal triggering time differed between subjects and needed to be individually optimized. To optimize the triggering time with our proposed MRS-method gave in average 13% higher signal than when the triggering time was determined through imaging. Lipid spectra acquired in systole demonstrated higher quality with improved SNR compared with acquisitions made in diastole. CONCLUSION: This study shows that the spectral quality in cardiac MRS is strongly dependent on the cardiac triggering time, and that the spectral quality as well as the repeatability between acquisitions is greatly improved when the cardiac triggering time is individually optimized in mid to end systole using MRS.

[Worldwide experience with automated external defibrillators: What have we achieved? What else can we expect?]. / Weltweite Erfahrungen mit automatisierten externen Defibrillatoren: Was haben wir erreicht, was können wir noch erwarten?

INTRODUCTION: In Germany approximately 70,000-100,000 SCD patients die from sudden cardiac death (SCD). SCD is not caused by a single factor but is a multifactorial problem. In 50 % of SCD victims, sudden cardiac death is the first manifestation of heart disease. SCD is caused by ventricular tachyarrhythmias in approximately 90 % of patients, whereas SCD is caused by bradyarrhythmias in 5-10 % of the patients. METHODS: Risk stratification is not possible in the majority of them prior to the fatal event. Early defibrillation is the method of choice to terminate ventricular fibrillation. Therefore, it is mandatory to install automatic external defibrillators (AED) in places with many people. There is general agreement that early defibrillation with automated external defibrillators (AED) is an effective tool to treat patients with ventricular fibrillation and will improve survival. CONCLUSION: It seems necessary to teach cardiocompression and AED use, also to children and adolescents. AED therapy "at home" did not improve survival in patients with cardiac arrest and can not be recommended.

[How does chocolate impact vascular function?]. / Wie beeinflusst Schokolade die Blutgefässe?

For thousands of years, cocoa have been a very popular food and has been linked to various beneficial health effects. Observational and epidemiological studies point towards a beneficial effect of dark chocolate on cardiovascular morbidity. Several small, albeit controlled studies indeed demonstrate an amelioration of endothelial dysfunction - the dysfunction of the inner layer of the vessels - after intake of dark, flavanol-rich chocolate. This is important, as endothelial dysfunction is an important marker of the development of atherosclerosis and an important prognosticator of future cardiovascular events. This article summarizes the actual literature in this respect.

Pendant des milliers d'années, le cacao a été une nourriture très populaire et liée à divers effets bénéfiques sur la santé. Les études d'observation et épidémiologiques pointent vers un effet bénéfique du chocolat noir sur la morbidité cardiovasculaire. Plusieurs petites études démontrent clairement une amélioration de la dysfonction endothéliale ­ le dysfonctionnement de la couche interne des vaisseaux ­ après la prise de chocolat noir, riche en flavanols. Cette dysfonction est importante, comme l'endothélium est un marqueur important de l'évolution de l'athérosclérose et un facteur pronostique important de futurs événements cardiovasculaires. Cet article vise à résumer la littérature à cet égard.

Accelerated radial Fourier-velocity encoding using compressed sensing.

PURPOSE: Phase Contrast Magnetic Resonance Imaging (MRI) is a tool for non-invasive determination of flow velocities inside blood vessels. Because Phase Contrast MRI only measures a single mean velocity per voxel, it is only applicable to vessels significantly larger than the voxel size. In contrast, Fourier Velocity Encoding measures the entire velocity distribution inside a voxel, but requires a much longer acquisition time. For accurate diagnosis of stenosis in vessels on the scale of spatial resolution, it is important to know the velocity distribution of a voxel. Our aim was to determine velocity distributions with accelerated Fourier Velocity Encoding in an acquisition time required for a conventional Phase Contrast image. MATERIALS AND METHODS: We imaged the femoral artery of healthy volunteers with ECG-triggered, radial CINE acquisition. Data acquisition was accelerated by undersampling, while missing data were reconstructed by Compressed Sensing. Velocity spectra of the vessel were evaluated by high resolution Phase Contrast images and compared to spectra from fully sampled and undersampled Fourier Velocity Encoding. By means of undersampling, it was possible to reduce the scan time for Fourier Velocity Encoding to the duration required for a conventional Phase Contrast image. RESULTS: Acquisition time for a fully sampled data set with 12 different Velocity Encodings was 40 min. By applying a 12.6-fold retrospective undersampling, a data set was generated equal to 3:10 min acquisition time, which is similar to a conventional Phase Contrast measurement. Velocity spectra from fully sampled and undersampled Fourier Velocity Encoded images are in good agreement and show the same maximum velocities as compared to velocity maps from Phase Contrast measurements. CONCLUSION: Compressed Sensing proved to reliably reconstruct Fourier Velocity Encoded data. Our results indicate that Fourier Velocity Encoding allows an accurate determination of the velocity distribution in vessels in the order of the voxel size. Thus, compared to normal Phase Contrast measurements delivering only mean velocities, no additional scan time is necessary to retrieve meaningful velocity spectra in small vessels.

[The effects of Omega-3 fatty acids in clinical medicine]. / Omega-3-Fettsäuren in der Medizin: Mechanismen, klinische Evidenz und Kontroversen.

Effects of Omega-3 fatty acids (n-3 FA) in particular on the development of cardiovascular disease (CVD) are of major interest. Many experimental studies reported their anti-inflammatory, anti-thrombotic and anti-atherosclerotic properties and suggested favourable effects on the prevention of CVD. While the majority of former studies showed a benefit of n-3 FA acid intake, recent clinical trials using n-3 supplements on top of established medication and prudent nutrition did not confirm these findings. The conflicting data may be due to several factors such as the selection of study population with different sizes or characteristics as well as choosing different doses or types of n-3 FA. The most recent meta-analyses observed clear benefits of fish consumption, but not of n-3 capsules intake. Furthermore, a nutrition rich in plant-derived n-3 FA alpha-linolenic acid has been found to have beneficial effects on the development of cardio- and cerebrovascular diseases.

Le rôle des acides gras oméga-3 dans la prévention de maladies cardiovasculaires a fait l'objet de recherches intenses. Ainsi plusieurs études expérimentales ont démontré leurs propriétés anti-inflammatoires et anti-thrombotiques. Cependant les récentes études épidémiologiques à grande échelle ont délivré des résultats ambivalents en ce qui concerne l'efficacité des acides gras oméga-3. En particulier, le choix de différentes sources d'acides gras, les différents dosages ainsi que les différences entre les populations étudiées semblent être à l'origine des divergences dans les résultats obtenus.