A case report of an elderly male with isolated coronary sinus atrial septal defect.

BACKGROUND: Isolated coronary sinus atrial septal defect (CSASD) is a rare congenital cardiac anomaly, comprising <1% of atrial septal defects. Elderly patients with this anomaly are even more uncommon and sometimes overlooked. CASE SUMMARY: A 73-year-old man with a history of electrical defibrillation therapy for atrial flutter presented with worsening exertional dyspnoea. Cardiac examination revealed CSASD without persistent left superior vena cava, showing only moderate tricuspid regurgitation. Surgical repair of the defect and regurgitant valve improved symptoms dramatically. DISCUSSION: Elderly patients with atrial arrhythmias might show uncommon presentations of congenital heart disease. Cardiologists should pay attention to enlarged right ventricle, pulmonary artery, and, in particular, enlarged coronary sinus. Direct closure with interrupted sutures secured with pledgets is effective in some case of terminal type of CSASD.

Frequent premature ventricular contractions induced by itraconazole.

Itraconazole is widely used to treat onychomycosis because of its significant therapeutic effects. An otherwise healthy 30-year-old man treated with itraconazole developed frequent premature ventricular contractions (PVC). He presented with a dry cough and palpitation. The results of 12-lead electrocardiography (ECG) were essentially normal, but Holter ECG revealed 17,484 (18%) uniform PVC, including 4 short runs among 96,930 beats/day. Another Holter ECG after withdrawing itraconazole revealed 1,032 premature atrial contractions but no PVC. The corrected QT interval was 0.39 s without itraconazole, 0.41 s with itraconazole, and 0.43 s when multiple PVC were documented. Itraconazole inhibits the fungal cytochrome P450 that is involved in fungal cell membrane formation, interrupts human cytochrome P450A4 in the liver and causes adverse interactions with various drugs such as antiarrythmics, but its cardiac side-effects are obscure. Both patients and physicians should be aware that itraconazole can cause PVC as a side-effect.

Challenge to detect 1,4-zwitterions spectroscopically in a ketene-alkene reaction.

The first example of direct spectroscopic detection of transient species, 1,4-zwitterions, generated in a ketene-alkene reaction is reported. Also, a striking result of the intervention of an unprecedented "1,4-zwitterion neutral dimer" is presented in a new mechanistic pathway; the ketene-alkene reaction gives the product cyclobutanone from the initial cycloadduct alpha-methyleneoxetane.

Pomegranate extract improves a depressive state and bone properties in menopausal syndrome model ovariectomized mice.

Pomegranate is known to contain estrogens (estradiol, estrone, and estriol) and show estrogenic activities in mice. In this study, we investigated whether pomegranate extract is effective on experimental menopausal syndrome in ovariectomized mice. Prolongation of the immobility time in forced swimming test, an index of depression, was measured 14 days after ovariectomy. The bone mineral density (BMD) of the tibia was measured by X-ray absorptiometry and the structure and metabolism of bone were also analyzed by bone histomorphometry. Administration of pomegranate extract (juice and seed extract) for 2 weeks to ovariectomized mice prevented the loss of uterus weight and shortened the immobility time compared with 5% glucose-dosed mice (control). In addition, ovariectomy-induced decrease of BMD was normalized by administration of the pomegranate extract. The bone volume and the trabecular number were significantly increased and the trabecular separation was decreased in the pomegranate-dosed group compared with the control group. Some histological bone formation/resorption parameters were significantly increased by ovariectomy but were normalized by administration of the pomegranate extract. These changes suggest that the pomegranate extract inhibits ovariectomy-stimulated bone turnover. It is thus conceivable that pomegranate is clinically effective on a depressive state and bone loss in menopausal syndrome in women.

Exclusive formation of alpha-methyleneoxetanes in ketene-alkene cycloadditions. Evidence for intervention of both an alpha-methyleneoxetane and the subsequent 1,4-zwitterion.

This paper describes a new mechanistic feature for the Staudinger ketene-alkene cycloaddition reactions to give cyclobutanones. Low-temperature NMR (13C, 19F, and 1H) monitoring of a reaction between bis(trifluoromethyl)ketene (1) and ethyl vinyl ether (2) has shown that the Staudinger reaction proceeds to form initially and exclusively an alpha-methyleneoxetane (3) by [2 + 2](C=O) cycloaddition across the ketene C=O bond. The initial intermediate 3 undergoes ring cleavage to produce a 1,4-zwitterion (4), which is converted to the final [2 + 2](C=C)-type product, cyclobutanone (5). The key intermediate 3 has been isolated in its pure form and was found to be converted to the final products 5 on warming, via the 1,4-zwitterion 4. The alpha-methyleneoxetane 3 is so reactive that it reacts with methanol rapidly even at -80 degrees C via solvolysis to afford an adduct 7. The ion 4 derived from the pure isolated oxetane 3 was intercepted with acetone by a 1,4-dipolar cycloaddition to give a 1,3-dioxane 8. An open-chain alpha,beta-enone (6) has been also obtained from 3. We conclude that the (1 + 2) reaction proceeds in a new three-step mechanism; formation of an alpha-methyleneoxetane 3, a [2 + 2]-type cycloadduct across the C=O bond of ketene, followed by ring cleavage to give the zwitterion 4 and by recombination to form the final product, cyclobutanone 5. The zwitterion 4 is not equilibrating with reactants 1 and 2 but comes from the alpha-methyleneoxetane 3. Exclusive formation of another oxetane 12 has been observed in a reaction between diphenylketene (9) and methyl isopropenyl ether (11). The selectivity of initial formation of cyclobutanone or oxetane has been generalized with aid of frontier-orbital theory and ab initio calculations.