Bartonella quintana endocarditis of the tricuspid and mitral valves.

Bartonella quintana is a gram-negative microorganism that can lead to culture-negative infective endocarditis (IE) in immunocompromised patients. Here, we present an exceptionally rare case of a 70-year-old male with Bartonella quintana-associated IE primarily limited to the tricuspid valve that spread to the mitral valve after tricuspid valve replacement. This was then complicated by infective spondylodiscitis of the thoracic vertebrae, ultimately resulting in death due to cardiac arrest.

Use of intravenous etomidate to control acute psychosis induced by the hypercortisolaemia in severe paediatric Cushing's disease.

BACKGROUND: Psychosis secondary to paediatric Cushing's disease (CD) is extremely rare and presents a significant management challenge. METHOD: We report a 14.7-year-old CD patient with acute psychosis and self-inflicted injuries following failed transsphenoidal pituitary surgery. Her mental state rapidly deteriorated precluding medical therapy. RESULTS: Emergency intravenous low-dose etomidate infusion (3-3.5 mg/h) with dose titration according to the serum cortisol combined with a hydrocortisone infusion, in an intensive care setting, was effective in controlling the hypercortisolaemia. Her mental state improved with normalisation of her cortisol levels enabling oral administration of ketoconazole and bilateral adrenalectomy to be performed. CONCLUSION: This case illustrates the safe and effective use of a low-dose etomidate infusion in an unusual case of paediatric CD.

Effect of multiple intravenous injections of butaphosphan and cyanocobalamin on the metabolism of periparturient dairy cows.

Numerous adjunct therapeutic agents have been investigated for the treatment or control of fat mobilization syndrome in periparturient dairy cows. The aim of this study was to determine the effects of multiple i.v. injections of 10% butaphosphan and 0.005% cyanocobalamin combination (Catosal, Bayer Animal Health, Leverkusen, Germany) between 1 and 2 wk antepartum (a.p.) on the metabolism and health of dairy cows. Forty-five late-gestation Holstein-Friesian cows (second pregnancy) were allocated randomly to 1 of 3 groups with 15 cows/group: group C6 (6 daily i.v. injections of butaphosphan at 10 mg/kg of body weight (BW) and cyanocobalamin at 5 microg/kg of BW in the last 2 wk of gestation); group C3 (3 daily i.v. injections of butaphosphan at 10 mg/kg of BW and cyanocobalamin at 5 microg/kg of BW in the last week of gestation); and group C0 (equivolume daily i.v. injections of 0.9% NaCl solution). Serum biochemical analysis was performed on jugular venous blood samples that were periodically obtained a.p. and postpartum (p.p.). Health status and milk production were monitored p.p. Serum cyanocobalamin concentration increased in groups C6 and C3 p.p. Multiple daily i.v. injections of Catosal before parturition increased p.p. glucose availability, as evaluated by p.p. serum glucose concentration, and decreased peripheral fat mobilization and ketone body formation, as evaluated by p.p. serum nonesterified fatty acid and beta-OH butyrate concentrations. The number of puerperal infections in the first 5 d after calving was decreased in group C6, relative to group C0. We conclude that multiple injections of Catosal during the close-up period have a beneficial effect on the metabolism of periparturient dairy cows. Our results are consistent with the hypothesis that high-producing dairy cows in early lactation may have a relative or actual deficiency of cyanocobalamin.

Traumatic arteriovenous fistula of the internal mammary vessels.

An uncommon case of traumatic arteriovenous fistula of the left internal mammary artery following penetrating chest trauma is presented. The patient developed a left parasternal machinery murmur six days after thoracotomy to repair a pericardial tamponade after a penetrating left parasternal stab wound. Selective digital subtraction angiography revealed pseudoaneurysm formation with fistulous connection of the left internal mammary artery to the adjacent vein. The fistula was successfully occluded with coil embolization.

Effect of closed minimized cardiopulmonary bypass on cerebral tissue oxygenation and microembolization.

OBJECTIVE: Coronary artery bypass grafting with cardiopulmonary bypass carries a risk for neurologic complications because of cerebral hypoperfusion and microembolization. The basic goals of a novel closed minimized extracorporeal circulation are to prevent excessive hemodilution and to avoid blood-air interface. The aim of this prospective randomized study was to determine the effect of using the minimized extracorporeal circulation system compared with open conventional extracorporeal circulation on cerebral tissue oxygenation and microembolization. METHODS: Forty patients undergoing coronary artery bypass grafting (20 in each group) were continuously monitored for changes in cerebral oxygenated hemoglobin and tissue oxygenation index by using near-infrared spectroscopy. Total microembolic count and gaseous embolic count in both median cerebral arteries were monitored with multifrequency transcranial Doppler instrumentation. RESULTS: In the conventional extracorporeal circulation group there was a highly significant reduction in both cerebral oxygenated hemoglobin and tissue oxygenation index from the start to the end of cardiopulmonary bypass (P < .01). The rate of decrease in cerebral oxygenated hemoglobin after aortic cannulation was faster in the conventional extracorporeal circulation group (F test = 9.03, P < .001). No significant changes with respect to cerebral oxygenated hemoglobin or tissue oxygenation index occurred in the minimized extracorporeal circulation group, except at the beginning of rewarming (P < .01). Total embolic count, as well as gaseous embolic count, in the left and right median cerebral arteries was significantly lower in the minimized extracorporeal circulation group (all P < .05). Postoperative bleeding was greater (P < .05) and the transfusion rate was higher (P < .05) in the conventional extracorporeal circulation group. CONCLUSIONS: Use of closed minimized cardiopulmonary bypass compared with conventional open cardiopulmonary bypass preserves cerebral tissue oxygenation and reduces cerebral microembolization.

Occurrence of Isospora suis in Germany, Switzerland and Austria.

Nationwide surveys for the occurrence of Isospora suis were carried out in Germany, Austria and Switzerland including a questionnaire regarding herd size, health status and management practices and a coccidiosis sampling kit for pooled faecal samples from litters of suckling piglets. A total of 184 veterinary practices participated in the survey and returned 1745 samples (331 kits) from 324 farms in the north (n = 98), south (n = 84), centre/east (n = 42) and west (n = 10) of Germany, Austria (n = 61) and Switzerland (n = 29) with larger farms in north and centre/east (average number of sows: 270 and 500) and smaller ones in the south (95), Austria (60) and Switzerland (43). Larger farms tended to have better hygienic standards (slatted floors, disinfection of the farrowing units). The majority of the participating farms (93.5%) reported problems with diarrhoea in piglets at 2-3 weeks of age, significantly associated (P < 0.001) with uneven weaning weights (94.9%). Toltrazuril (5%; Baycox) was used only rarely; however, in these farms unevenness of weaning weights was less frequently observed (P = 0.011). A 76.2% of the farms were positive for I. suis (samples contained mostly low or moderate oocyst numbers), especially in the south (P < 0.001). Oocysts were more frequently found in samples from farms with reported diarrhoea (P = 0.011), uneven weight gain (P = 0.019) or in herds of small size (P < 0.001). Disinfection, floor type or treatment with toltrazuril did not affect the frequency of observation of oocysts.

CABG and bone marrow stem cell transplantation after myocardial infarction.

OBJECTIVE: Bone marrow-derived adult stem cells may be able to regenerate infarcted myocardium. We initiated a phase-I study of autologous stem cell transplantation in patients undergoing coronary artery bypass grafting. METHODS: Inclusion criteria were: acute myocardial infarction > 10 days ago; presence of a distinct area of infarcted and akinetic myocardium; CABG indicated to treat ischemia of other LV wall areas. Stem cells were isolated from bone marrow using a ferrite-conjugated AC133 antibody, and were injected in the infarct border zone during the CABG operation. RESULTS: To date, 12 patients were treated without major complications. There is no evidence of new ventricular arrhythmia or neoplasia. Scintigraphic imaging demonstrated significantly improved local perfusion in the stem cell-treated infarct area. LV dimensions (LVEDV 140 +/- 38 ml vs. 124 +/- 30 ml, p = 0.004, paired t-test) and LV ejection fraction (39.7 +/- 9 % vs. 48.7 +/- 6 %, p = 0.007) have improved. CONCLUSIONS: Bone marrow stem cell transplantation for myocardial regeneration can be safely performed in humans. There is evidence of improved revascularization and contractility of infarct areas, but controlled studies are needed to clearly determine the clinical benefit.

[Perforated mitral valve aneurysm as a rare course of bacterial endocarditis]. / Perforiertes Mitralklappenaneurysma als seltene Verlaufsform einer bakteriellen Endokarditis.

A 65 year old man with a history of mechanical aortic valve replacement acquired Enterococcus faecalis mediated infective endocarditis about 3 years later. Transesophageal echocardiography revealed formation of an aneurysm confined to the anterior mitral valve leaflet. The aortic valve revealed no signs of endocarditis by transesophageal ultrasound. With sudden perforation of the mitral valve aneurysm, subsequent hemodynamic deterioration and pulmonary oedema, the patient underwent emergency mitral and aortic valve replacement. The postoperative course was uneventful.

Diagnosis of patients presenting to a Huntington disease (HD) clinic without a family history of HD.

About 9% of patients presenting to a Huntington disease (HD) clinic for evaluation of possible HD lacked a family history of the disorder. HD was the final diagnosis in 53 to 83% of these patients. As a group, HD-affected individuals without a family history of HD were older and had fewer CAG repeats than the average HD patient. Some patients presenting with chorea only had HD and others did not; patients developing a movement disorder after long-standing neuroleptic-treated psychiatric illness did not have HD.

[Successful resuscitation of a hypothermic patient with extracorporeal circulation--a case report]. / Erfolgreiche Reanimation eines unterkühlten Patienten mittels Extrakorporaler Zirkulation--Ein Fallbericht.

A case of cardiopulmonary arrest due to accidental hypothermia and its successful therapy is described. A 46-year-old man with deep accidental hypothermia (25.3 degrees C esophageal) was found outside showing respiratory and cardiac arrest. Resuscitation was immediately started and continuously performed during the transport to the University Hospital of Rostock, where a treatment with extracorporeal circulation was possible. After cardiopulmonary resuscitation for 120 minutes, the patient could finally be connected to the extracorporeal circulation. Over a period of 130 minutes the patient could be rewarmed up to a body temperature of 36.0 degrees C. The following therapy was complicated by the development of an alcoholic delirium, which was treated by clomethiazol, droperidol and clonidin infusion. After seven days of intensive therapy, he recovered completely and could be transferred from the intensive care unit to the department of psychiatry without neurological deficits showing only healing of frostbite of the feet. Based on this case report, the use of extracorporeal circulation for adequate rewarming in combination with cardiopulmonary resuscitation is described. Compared to other therapeutic measures such as peritoneal dialysis or veno-venous haemofiltration treatment with extracorporeal circulation is the method of choice.

[Perinatal and neonatal mortality and morbidity in newborn infants up to 1,000 g]. / Perinatale und neonatale Mortalität und Morbidität bei Neugeborenen bis 1000 g.

World-wide intensive efforts have been made for more than 20 years to reduce the rate of preterm delivery, but so far without remarkable success. Preterm delivery accounts for 6-9% of all deliveries and very-low-birth-weight infants (< or = 1000 g) total up to about 60% of perinatal mortality. This study reports on a retrospective analysis of fetal outcome with 33 very-low-birth-weight-infants (< or = 1000 g) delivered at the Women's Hospital (University of Rostock) during the time from 1986 to 1992. The rate of early mortality was at 45.2%, survival rate was at 33% (n = 11). Caesarean section with preservation of fetal membranes proved to offer better results of fetal outcome than spontaneous delivery. Comparing the fetal outcome of all patients concerned, it became obvious that newborns whose mothers enjoyed intensive prenatal care had better chances than those newborns whose mothers came to hospital not before onset of preterm labour. From our experiences we conclude that intensive antenatal care with very early assessment of all possible risk factors for preterm labour is the prerequisite to reduce the rate of preterm delivery.

A pilot study of hyperbaric oxygen in the treatment of human stroke.

We administered hyperbaric oxygen or air in a double-blind prospective protocol to 39 patients with ischemic cerebral infarction. We interrupted the study when we noticed what appeared to be a trend favoring the air-treated patients, whose neurological deficits were less severe (mean +/- SEM score on graded neurological examination: air, 25.6 +/- 4.9; oxygen, 34.5 +/- 7.5) and whose infarcts were smaller (air, 29.0 +/- 12.2 cm3; oxygen, 49.2 +/- 11.7 cm3) at 4 months. The trend, we decided, was probably an artifact of the randomization process. Nevertheless, we chose not to resume the trial because the treatment was difficult to administer by schedule (for various reasons the treatment protocol was broken in 15 of the 39 patients), was poorly tolerated (eight of the 39 patients refused to continue treatments), and did not produce dramatic improvement.

Orthodromic and antidromic pacemaker circus movement tachycardia.

Pacemaker circus movement tachycardia (PCMT) during DDD pacing is usually sustained by retrograde natural and antegrade electronic atrioventricular (AV) conduction. As PCMT is often initiated by a ventricular premature beat (VPB) one method of its prevention is the programming of an atrial stimulus synchronously following a ventricular extrasystole. A patient is described with preserved antegrade, but without retrograde, i.e., VA, conduction. The optional pacemaker mode of synchronous atrial stimulation following a VPB caused an unusual PCMT sustained by retrograde electronic and antegrade natural AV conduction. This PCMT is similar to a natural reentry tachycardia, the most common variety of which (based on retrograde conduction) is termed antidromic and that which we describe is orthodromic.

[Results of early education of developmentally delayed infants and young children by parents with a clinical rehabilitation program]. / Ergebnisse der Frühförderung von entwicklungsgestörten Saüglingen und Kleinkindern durch Eltern mit einem klinisch-rehabilitativen Rahmenprogramm.

Early registration of disturbances in the development of infants was based on neurological examination. Since 1984 exists the possibility of psychological evaluation of infants and children in early childhood in the Department of Paediatrics of the University of Rostock. Parents of children suffering from disturbances of development receive additionally to the concept of physiotherapy an early intervention program to furtherance of children. In this way best conditions are prepared in development and evaluation of admission in special institutions (special kindergarten, day-nursery).

[Cytogenetic detection of Prader-Willi syndrome in infancy]. / Zytogenetischer Nachweis eines Prader-Willi-Syndroms im Säuglingsalter.

In the case of characteristic chromosomal deletion of chromosome 15(q11----q13) the diagnosis of the Prader-Willi syndrome can be already confirmed in early infancy as shown in our case report. In this connection cytogenetic high-resolution techniques are indispensable. Cytogenetic and clinical problems are discussed.