Aortopexy offers surgical options for a variety of pathological tracheal conditions in paediatric patients.

OBJECTIVES: Aortopexy is widely used; however, many surgeons still regard it with suspicion. To date, there are only a few large series and minimal long-term data. Against this background, our goal was to report our experience, particularly with regard to the recent expansion of indications and modification of diagnostic routine and surgical strategy. METHODS: Between 1994 and 2012, 53 patients (mean age: 1.1 years; 5 weeks-10.2 years) were operated on. Tracheomalacia after the operation for oesophageal atresia was the main indication for aortopexy (74%), followed by tracheal compression by the innominate artery (17%) and other selected indications (9%). Computed tomography angiography has emerged in recent years as the method of choice for preoperative diagnosis. Median sternotomy has replaced lateral thoracotomy, and intraoperative bronchoscopy has become the standard. RESULTS: In contrast to magnetic resonance imaging, computed tomography angiography resulted in perfect visualization of the condition. Median sternotomy and simultaneous bronchoscopy led to immediate readjustment of the aortopexy sutures in 6 patients. There were no surgical deaths or serious morbidities. The mean follow-up was 4.9 (0.3-14.9) years. Two patients with additional complex diseases died during the follow-up period. In all survivors, symptoms improved markedly or disappeared. However, we observed an increased susceptibility to lower respiratory tract infections over the long-term (32%). CONCLUSIONS: Aortopexy is effective for treating tracheomalacia of different origins and other pathological conditions as well. Preoperative computed tomography angiography offers excellent visualization of the condition. Median sternotomy and intraoperative bronchoscopy provide a combination for reliable operative and long-term results. However, many patients still have an increased susceptibility to lower respiratory tract infections.

Magnetic resonance-guided placement of atrial septal closure device in animal model of patent foramen ovale.

BACKGROUND: Percutaneous closure of the patent foramen ovale (PFO) is usually performed under x-ray in combination with ultrasound guidance. We tested the feasibility of applying magnetic resonance (MR) guidance for percutaneous closure of PFO in an animal model, thus avoiding the disadvantage of ionizing radiation. METHODS AND RESULTS: Real-time MRI with radial or spiral k-space filling (15 frames per second) on an interventional 1.5-T high-field whole-body system was exploited to examine the feasibility of MR-guided closure of the PFO in 7 piglets weighing approximately 14 kg. A specially designed prototype nonmagnetic closure device was introduced via the femoral vein. The short bore of the magnet and in-room monitors allowed for visualization and steering of the catheter with the loaded occluder. Catheterization of the left atrium and, finally, correct placement of the device was possible in all animals. Deployment of the device was depicted by real-time MR, and initial misplacement, which occurred in 2 animals, was easily detected and corrected. CONCLUSIONS: Real-time MR guidance of PFO closure, without the use of ionizing radiation, is feasible in an animal model.

Regulation of Gadd45a mRNA expression in vascular smooth muscle under growth and stress conditions.

In order to identify differentially expressed genes under growth conditions, quiescent vascular smooth muscle cells (VSMCs) were stimulated with foetal calf serum (FCS) or platelet-derived growth factor-BB (PDGF-BB) for different time periods. Analysing the gene expression by the differential display (DD) method, we identified the cDNA of the growth arrest and DNA damage inducible gene 45a (Gadd45a, also known as gadd45 and gadd45a). Treatment with FCS or PDGF-BB led to a transient down-regulating of Gadd45a expression during the G0/G1 phase and maximal expression when cells had completed division. We found that expression of p53 and BRCA1 mRNA precedes Gadd45a mRNA expression with a maximal induction in the S phase. As in smooth muscle cells, a similar pattern of the Gadd45a mRNA expression was observed in knockout Gadd45a(-/-) cultured mouse embryonic fibroblasts (MEFs). However, no differences between Gadd45a(+/+) and Gadd45a(-/-) cell lines were observed regarding their kinetics of cell division. These experiments suggest a function of Gadd45a when cells exit the cell cycle rather than when regulating the entry into the S phase.

Plasma prostaglandin E2 metabolite--measured as 11-deoxy-15-keto-13,14-dihydro-11 beta,16 xi-cyclo-PGE2--in twins with schizophrenic disorder.

Blood samples were obtained from 18 twin pairs, and the major prostaglandin E2 (PGE2) plasma metabolite 15-keto-13,14-dihydro-PGE2 was measured by RIA after its conversion to 11-deoxy-15-keto-13,14-dihydro-11 beta,16 xi-cyclo-PGE2. Significant positive correlations were found in all the twin pairs, in 11 pairs diagnosed as DSM-III schizophrenic disorder and schizoid/schizotypal personality disorder, and in the 5 nonschizophrenic pairs. These results indicate that synthesis of prostaglandins (PGs) is in part genetically determined. With regard to absolute PGE2 metabolite levels, the data did not support the hypothesis of increased PGE2 in schizophrenia. Thus, seven of eight schizophrenic probands had lower metabolite concentrations than their healthy twin siblings, and in one pair they were similar. Furthermore, schizophrenic probands and their healthy sibling controls, taken as a group, had lower PGE2 metabolite levels than the group comprised of affective disorder probands and their respective controls. These findings raise the possibility that a change in PGE2 may be associated with schizophrenic and also possibly with affective disorders.

[3H]imipramine binding in idiopathic pain syndromes. Basal values and changes after treatment with antidepressants.

The binding affinity (Bmax, Kd) of [3H]imipramine to platelet membranes was investigated in 43 patients with a diagnosis of idiopathic pain syndrome. Measurements were carried out prior to and after 6 weeks' treatment with the antidepressants clomipramine or maprotiline (randomized double-blind trial). Before treatment the Bmax was 11% lower (1109 +/- 237 fmol/mg protein) compared to historical control subjects (n = 21, 1240 +/- 390) and comparable to patients with psychogenic pain with affective symptoms (n = 62, 1110 +/- 360) previously measured at the same laboratory. The Kd was 0.5 +/- 0.3 nM comparable to the Kd of the controls (0.6 +/- 0.2). After 6 weeks of treatment the clomipramine group (n = 11) had significantly lower Bmax = 208.5 +/- 286 (P less than 0.001). In the maprotiline-treated patients (n = 18) the Bmax values (1221 +/- 258) tended to increase towards the values of the controls but without statistical significance. No significant statistical correlation was found between initial Bmax values and clinical outcome.

Normative melatonin excretion: a multinational study.

The present study on overnight urinary melatonin was conducted on the most geographically dispersed population to date, over a 1 year period, also covering a broad age range (18-62 years). An inverse relationship between melatonin and age, as well as between melatonin and weight was observed for both genders. Females as a whole, had higher melatonin values than males. Furthermore, the excretion of melatonin exhibited a bimodal distribution, distinguishing two groups of individuals: low and high melatonin excretors. The cut-off point was set at 0.25 nmol/l for ages up to 40 years and at 0.20 nmol/l for subjects above this age. Since melatonin may be involved in several physiological and pathological processes, it could be of importance to detect the type of melatonin excretion that prevails in various conditions, using a simple noninvasive procedure such as the overnight urinary measurement. For that purpose, this large sample could serve as a worldwide reference databank across different ages and locations.

Psychoses in twins. A 10 year clinical and biochemical follow-up study.

An unbiased sample of monozygotic and dizygotic twins with psychotic or pre-psychotic symptoms has been followed during a 10 year period. The sample was based on 9000 patients, both born in 1930-1946, and hospitalized in Scania, Sweden, during the 1960s. 23 complete pairs were examined in 1972 with regard to a variety of clinical, genetic, and biochemical parameters. A fairly young sample was chosen in order to include a sufficient number of discordant pairs to be followed prospectively, thus making it possible to study a group of individuals with a very high risk of developing psychosis. 18 of the 23 pairs were re-examined by the same clinician 10 years later. The biochemical methods were both partly the same as those used 10 years earlier and partly extended. Very few changes in the clinical diagnoses of the twins were noted during the follow-up period. A highly significant correlation was found between 1972 and 1982 activity both for catechol O-methyltransferase (COMT) and for monoamine oxidase (MAO). The basal levels of MAO, COMT, dopamine beta-hydroxylase (DBH) and serotonin (5-HT) did not show correlations to the presence of pre-psychotic or psychotic symptoms.

Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches.

BACKGROUND: Although patients after Fontan procedure have a high incidence of thromboembolic complications, anticoagulant therapy is not handled uniformly. We analyzed the frequency and clinical relevance of thromboembolism after Fontan procedure and compared different therapeutic approaches. METHODS: From 1986 to 1998, 101 patients (mean age, 7.3 +/- 8.1 years) underwent Fontan type procedure (modified Fontan, n = 40; total cavopulmonary connection, n = 61). In 85 of 87 survivors, transthoracic echocardiography was performed; and in 31 transesophageal echocardiography and/or angiography was performed. Mean follow-up was 5.7 +/- 3.5 years. Three groups with different anticoagulant regimen were compared: group I without medication (n = 45), group II with acetylsalicylic acid therapy (n = 14) and group III with Coumadin (n = 26). RESULTS: Thromboembolic events occurred in 13 of 85 patients (15.3%; 3.3 events/100 patient-years). Type of operation as well as other known risk factors had no influence on the rate of thromboembolism. Within the first postoperative year, seven of 13 events occurred. A second peak developed beyond 10 years of follow-up. Patients benefit significantly from Coumadin compared with those who did not receive any medication, with similar results in the entire population and the subgroup of patients with total cavopulmonary connection (log-rank, p = 0.031 and p = 0.033, respectively). With 4.2 events/100 patient-years, the cumulative event rate was substantially higher in group I than with 1.6 in group II and with 1.1 in group III. No relevant bleeding complications occurred. CONCLUSIONS: Thromboembolism is frequent after Fontan procedure with a peak during the first postoperative year and another peak beyond 10 years of follow-up. Coumadin is the most effective prophylactic therapy in preventing thromboembolism. Therefore, we suggest initial oral anticoagulation therapy in patients with Fontan type operation.

Efficacy and safety of risperidone in the long-term treatment of patients with schizophrenia.

The long-term efficacy and safety of risperidone were evaluated in patients with chronic schizophrenia in an open-label study. Thirty-two patients received risperidone for 1 year and 19 of the 32 received risperidone for 2 years. The mean dose of risperidone was 9.4 mg/d in the 1-year follow-up. At the end of 1 and 2 years, improvements were found in total scores on the Positive and Negative Syndrome Scale (PANSS), on four PANSS factors (positive, negative, excited, and cognitive), and the Clinical Global Impression scale. Severity of extrapyramidal symptoms (based on scores on the Extrapyramidal Symptom Rating Scale) was also reduced. Clinical improvement (defined as a 20% or more reduction in total PANSS scores) was shown by 54% of the patients at end point. Social functioning (as assessed by using the modified Strauss/Carpenter scale) was significantly improved after 2 years. Number of days spent in hospitals was significantly reduced during the 2 years of treatment, and the number of days in treatment (group) homes significantly increased. It is concluded that treatment with risperidone for 1 and 2 years is associated with significant reductions in symptoms of schizophrenia, improved social functioning, and reduction in days spent in the hospital.

A double-blind multicenter trial comparing sertraline and citalopram in patients with major depression treated in general practice.

The purpose of this double-blind, multicenter trial was to compare the efficacy and safety of sertraline (50-150 mg/day) with those of citalopram (20-60 mg/day) in patients with major depression in general practice during 24 weeks of treatment. The patients were assessed using the Montgomery-Asberg Depression Rating Scale and the Clinical Global Impressions of severity and improvement scales. Observed and spontaneously reported adverse events were recorded and side-effects were assessed by means of the UKU Side-Effect Scale. Altogether 400 patients were randomized into the study. A total of 308 patients completed the 24-week study in accordance with the protocol. A significant reduction in the total Montgomery-Asberg Depression Rating Scale scores was observed in both treatment groups as early as 2 weeks, with no statistically significant differences between the drugs. In the intention to treat-last observation carried forward analysis 76% responded to treatment in the sertraline and 81% in the citalopram group. The final mean doses were 82 mg/day (64% higher than baseline) in the sertraline group and 34 mg/day (70% higher than baseline) in the citalopram group. The response rate in completers in accordance with protocol was 90% in the sertraline group and 93% in the citalopram group. The side-effects were those usually seen, and both sertraline and citalopram were considered to be well tolerated. It was concluded that patients with major depression in general practice respond well to 24 weeks of treatment with sertraline or citalopram. With regard to efficacy, no statistically significant differences were found between the drugs.

A chip card for patients with diabetes.

DIABCARD provides the specification for the core of a Chip Card Based Medical Information System (CCMIS) for the treatment of patients with chronic diseases. It will provide an instrument for assessing health care services, improve the links between health care providers and set up communication between the different levels of health care. It will therefore improve the quality of care and thus the life of patients with chronic diseases. DIABCARD concentrates on diabetes at the moment, the concept of the diabetes chip card will, however, be extendable to other chronic diseases.

Pancarditis in a five-year-old boy affecting tricuspid valve and ventricular septum.

A five-year-old boy with a structurally normal heart and recent history of adenotomy and gastroenteritis presented with Staphylococcus aureus pancarditis including endocarditis of the tricuspid valve and abscess of the ventricular septum. Surgical treatment consisted of debridement of the valvar vegetations and of the septal abscess. A seven-day continuous mediastinal irrigation with iodine solution was conducted to eliminate local infection sites as well as to prevent from constrictive pericarditis. The patient recovered uneventfully and is in excellent clinical condition with no residues one year after surgery.

Myocardial ischaemia in a child infected with influenza B.

Cardiac involvement is a rare complication of infection by the influenza B virus. It usually presents with ventricular dysfunction, arrhythmias, or both. We report a 13-year-old boy with clinical, electrocardiographic, and laboratory findings of myocardial ischaemia during an otherwise silent acute infection with influenza B. Coronary endothelial injury constituted a potential underlying mechanism, and microthrombosis was promoted by high levels of lipoprotein(a) in the serum.

Psychoses in twins - a longitudinal study. Introductory clinical report.

A sample of psychotic and prepsychotic twins is presented, based on 9000 patients born during 1930--1946 and admitted to psychiatric departments in Scania, Sweden, during the 1960's. All twins of the same sex (76 pairs) were registered and their records examined. Twenty-three complete pairs, where one or both twins showed psychotic or prepsychotic symptoms, were carefully examined with regard to different clinical, genetic, biochemical, and psychophysiological parameters. A fairly young sample was chosen in order to include a sufficient number of discordant pairs to be followed prospectively and thus making it possible to study a group of individuals exposed to a very high risk of developing psychoses. Of the 23 pairs, eight pairs were monozygotic, which is somewhat less than expected and may be due to the very careful diagnoses of zygosity which also included analysis of HL-A antigens. An account is given of material and methods, principles of sampling, and clinical data of all twin pairs. No less than 17 complete pairs were judged to be discordant for serious mental disturbance at the time of the examination. Brief histories of the monozygotic twin pairs are included.

Haloperidol decanoate and flupenthixol decanoate in schizophrenia. A long-term double-blind cross-over comparison.

Thirty-two schizophrenic patients, previously treated with antipsychotics, were treated with haloperidol decanoate and flupenthixol decanoate in a double-blind cross-over study. The drugs were given for 24 weeks each at an individually adapted dose. The last three injections of either drug were given at fixed 4-week intervals. The mean dose over the two treatment periods changed from 131 mg (start) to 151 mg (week 24) in the haloperidol decanoate group and from 56 mg to 66 mg in the flupenthixol decanoate group, the inter-drug ratio being 2.3:1. During the first study period, the patients' condition remained rather stable with both drugs. After crossing-over, the symptoms were further reduced with haloperidol decanoate but increased with flupenthixol decanoate. Side effects of the two drugs were comparable and were generally few and mild. It was concluded that 4-week intramuscular administration of haloperidol decanoate provides appropriate control of schizophrenic symptoms, but that flupenthixol decanoate should be dosed at shorter intervals.

Erythrocyte catechol-O-methyltransferase activity in psychotic twins.

Erythrocyte catechol-O-methyltransferase (COMT) activity was analyzed in 20 twin pairs, 6 monozygotic and 14 dizygotic, where one or both twins showed psychotic or prepsychotic symptoms. Fifteen of these pairs, 4 monozygotic and 11 dizygotic, were diagnosed as discordant for serious mental disturbance. The different psychotic states within twins did not seem to be associated with any difference in COMT activity.

Schizophrenia susceptibility and HL-A antigen.

The phenotype frequencies of HL-A specificities have been investigated in 47 chronic schizophrenics subdivided in an older and a younger group. The frequency of HL-A 9 was significantly increased in the psychotics as compared to a reference group of 1,263 healthy blood donors, pregnant women and potential kidney donors. Deviations in frequency were also found concerning W 19 and HL-A 5. As HL-A 9 was mainly found in the older group of schizophrenics, it is suggested that HL-A 9 might be associated to some form of schizophrenia with a chronic course.

Kinetic aspects of monoamine oxidase activity in twins with psychoses.

Monoamine oxidase activity was assayed in platelets from 22 (8 monozygotic and 14 dizygotic) twin pairs. At least one twin of each pair had a serious psychiatric disorder (proband). Phenethylamine was used as substrate and the assay was performed at two different oxygen concentrations (0.06 and 0.12 nM). Apparent Km and Vmax values were estimated from double reciprocal plots. The correlation between proband and control twins was high for both apparent Km (r = 0.83) and Vmax (r = 0.69) when the enzyme was assayed at the higher concentration of oxygen. The monozygotic twins pairs showed very high correlations (Km r = 0.93; Vmax r = 0.86) as compared to dizygotic twins (Km r = 0.81, Vmax r = 0.50) and apparently healthy subjects (Km r = 0.46, Vmax r = 0.33). No difference in kinetic properties was found between schizophrenic and non-schizophrenic twins.