Biopsychosocial factors associated with a current depressive episode in diabetes: the ELSA-Brasil study.

AIMS: Depression is more prevalent in people with diabetes, and is associated with worse diabetes outcomes. Depression in diabetes is more treatment resistant, and as underlying mechanisms are unknown, development of more effective treatment strategies is complicated. A biopsychosocial model may improve our understanding of the pathophysiology, and therewith help improving treatment options. METHODS: Diabetes was diagnosed according to American Diabetes Association (ADA) criteria and a current depressive episode according to the International Classification of Diseases (ICD-10), based on the Clinical Interview Schedule Revised (CIS-R). From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), we included 455 participants without diabetes with a current depressive episode and 10 900 without either diabetes or a current depressive episode. Furthermore, 2183 participants had diabetes alone and 106 had both diabetes and a current depressive episode. Variable selection was based on their relationship with depression and/or diabetes. Multinomial multivariate logistic regression was used to determine how the models differed between participants with and without diabetes. RESULTS: A current depressive episode in diabetes was related to being older and female, having poorer education, financial problems, experiencing discrimination at work, home and school, higher waist circumference, albumin to creatinine ratio and insulin resistance, and the presence of hypertension and cardiovascular disease. In non-diabetes, a current depressive disorder was related to being female, not being black, low income, psychological and social factors, non-current alcohol use, lower HDL cholesterol, higher insulin resistance and the presence of cardiovascular disease. CONCLUSIONS: A current depressive episode in the presence compared with the absence of diabetes was related more to biological than to psychosocial factors.

MODY diabetes and screening of gestational diabetes.

OBJECTIVE: The aim of this article is to present a summary of the actual diagnostic possibilities and differentiation of MODY (Maturity-Onset Diabetes of the Young) from gestational diabetes (GDM) found during routine screening, and specific aspects of care and treatment of MODY during pregnancy and early postpartum period. DESIGN: Rewiev. SETTINGS: Centre for Research of Diabetes, Metabolism and Nutrition; Second Department of Internal Medicine University Hospital Královské Vinohrady and Third Faculty of Medicine, Prague. Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague. METHODS: Recent publications selected in PubMed with the key words MODY, gestational diabetes. RESULTS: Many patients with MODY, especially the glucokinase MODY, can be first diagnosed during pregnancy. It is estimated that MODY patients account for up to 5% of GDM cases found in routine screening of GDM. MODY should be considered in lean women around 25 years of age, with a positive family history of diabetes in one of the parents. The differentiation of MODY from GDM is of particular importance not only for the different management and goals of antidiabetic therapy and planning ultrasound controls of fetal growth during pregnancy, but also because of the risk of hyperinsulinemic hypoglycemia in newborns. CONCLUSION: Recognition of MODY during pregnancy and adherence to existing recommendations concerning specific care of these patients is essential for the optimal course of their pregnancy and proper care of the newborn in the early postpartum period.

Secondary dengue infection in immunocompetent murine model leads to heart tissue damage.

Dengue, considered the most important arthropod-borne viral disease affecting humans, is transmitted by the bite of mosquitoes of the genus Aedes and caused by one of the four distinct serotypes of dengue virus (DENV-1, -2, -3 and -4). Infection with one of the four serotypes provides lifelong homotypic immunity. However, immunity against the heterologous serotypes is transient. As a consequence, secondary infection may lead to severer manifestations due to cross-reactivity of antibodies and T-cells. Over 500,000 people are hospitalized every year and around 2,5 million, living in endemic areas, are at risk of infection. Given the background, the development of vaccines and anti-DENV drugs is of the utmost importance, as is the characterization of an animal model for testing them. The purpose of this study was to investigate ultrastructural alterations caused by DENV secondary infection in BALB/c mice heart. To achieve our goal, six BALB/c mice were infected with DENV-1 and, 4 months later, reinfected with DENV-2. Uninfected mice were used as negative controls. Heart samples were collected and processed for ultrastructural and histopathological analysis. Our results showed edema, endothelium activation characterized by the presence of transport vesicles, free platelets in interstitium, mitochondria presenting rarefied matrix and degenerated cristae, and disorganization of muscle fibers. These results point not only to BALB/c mice susceptibility to DENV infection, but also to the fact that, although it is not an often reported occurrence, dengue can lead to heart damage. Keywords: dengue; experimental model; reinfection; BALB/c mice.

Moderate hypoxia is able to minimize the manganese-induced toxicity in tissues of silver catfish (Rhamdia quelen).

The aim of this study was to compare the effects of manganese (Mn) on silver catfish exposed to different levels of dissolved oxygen. Silver catfish (Rhamdia quelen) were exposed to increasing concentrations of Mn (4.2, 8.4 or 16.2mgL(-1)) under either normoxia (100 percent saturation) or moderate hypoxia (51.87 percent saturation) for 15 days. Under normoxia, Mn exposure increased lipid peroxidation (LP) in brain and kidney; it increased gluthatione (GSH) levels in brain and decreased catalase (CAT) activity in both tissues. Moderate hypoxia was able to prevent Mn-induced LP in brain and to reduce this oxidative parameter in kidney; GSH level was increased in brain, while CAT activity was reduced in both tissues. Activity of isolated mitochondria of liver and gills was reduced by Mn exposure under both levels of dissolved oxygen, but this effect was more prominent in normoxia. As expected, liver, kidney and gills showed an increase of Mn accumulation according to waterborne levels, and these parameters presented positive relationship. The highest waterborne Mn (8.4 and 16.2mgL(-1)) resulted in greater accumulation under normoxia, indicating that moderate hypoxia can stimulate mechanisms capable of reducing Mn accumulation in tissues (though not in blood). Moderate hypoxia can be considered a stress factor and Mn an aquatic anthropogenic contaminant. Therefore we hypothesized that these two conditions together are able to invoke defense mechanisms in juvenile silver catfish, acting in a compensatory form, which may be related to adaptation and/or hormesis.

Citrus leprosis virus C Naturally Infecting Commelina benghalensis, a Prevalent Monocot Weed of Citrus Orchards in Brazil.

There are two bacilliform, rhabdo-like viruses that cause citrus leprosis: Citrus leprosis virus C (CiLV-C), which accumulates in the cytoplasm of infected cells, and Citrus leprosis virus nuclear type (CiLV-N), which accumulates in their nucleus. The first one, the prototype of the new genus Cilevirus, is prevalent and occurs in several countries of the American continent, from Argentina to Mexico (1). The second type, still a tentative member of the Rhabdoviridae family, is of rare occurrence, with a few reports in Brazil and one in Panama (1). Leprosis is particularly important to the Brazilian citrus industry because of the 60 to 80 million dollars spent yearly for the control of Brevipalpus phoenicis (Geijskes, 1939) (Acari: Tenuipalpidae), the vector of the virus (1). For decades, the disease was considered unique to citrus plants; however, greenhouse experiments conducted in the 1990s demonstrated the mechanical transmission of CiLV-C to noncitrus plants (1). Years later, researchers were able to transmit the virus to nonrutaceous hosts using viruliferous mites (1,4). Recently, León et al. (2) reported the occurrence of the first noncitrus plant naturally infected by CiLV-C, the rutaceous Swinglea glutinosa Blanco (Merr.). Tropical spiderworts (Commelina benghalensis L.; Commelinaceae) are monocot weeds commonly found in citrus orchards in Brazil. In a survey conducted in orchards with high incidences of leprosis in the municipalities of Borborema and São José do Rio Preto, State of Sao Paulo, Brazil, tropical spiderworts were found exhibiting necrotic spots with a yellow halo in green leaves and green spots with necrotic center in senescent leaves. Since these symptoms are similar to those caused by CiLV-C in citrus, symptomatic plants were collected and subjected to transmission electron microscopy analyses and reverse transcription-PCR using primers that specifically amplify a region within the putative movement protein gene of the virus (3). Bacilliform virus particles and typical inclusions were seen in the lesions. Bands of the expected 344 bp size were seen in agarose gels of symptomatic samples only. The analysis of the consensus sequence showed 100% identity with CiLV-C sequence available in the GenBank (Accession No. YP_654542.1). Experimental transmission of CiLV-C by B. phoenicis reproduced the lesions in inoculated tropical spiderwort. Also, the virus could be easily transmitted back from C. benghalensis to sweet orange plants. Our data show that this widespread weed is the first monocot as a natural host for CiLV-C. Since tropical spiderwort is a host for B. phoenicis and symptomatic plants were found in two municipalities 130 km apart from each other, it is possible that this weed may serve as reservoir for the virus and play a relevant role in the spread of the disease in the field, but this issue still needs to be addressed in further experiments. References: (1) M. A. Bastianel et al. Plant Dis. 94:284, 2010. (2) M. G. A. Leon et al. Plant Dis. 90:682, 2008. (3) E. C. Locali-Fabris et al. Plant Dis. 87:1317. (4) M. A. Nunes et al. Plant Dis. Online publication. doi:10.1094/PDIS-06-11-0538, 2011.

Transmission of Citrus leprosis virus C by Brevipalpus phoenicis (Geijskes) to Alternative Host Plants Found in Citrus Orchards.

The equivalent of US$75 million is spent each year in Brazil to control Brevipalpus phoenicis, a mite vector of Citrus leprosis virus C (CiLV-C). In this study, we investigated the possibility that hedgerows and windbreaks normally found in citrus orchards could host CiLV-C. Mites confined by an adhesive barrier were reared on sweet orange fruit with leprosis symptoms then were transferred to leaves of Hibiscus rosa-sinensis, Malvaviscus arboreus, Grevilea robusta, Bixa orellana, and Citrus sinensis. Ninety days post infestation, the descendant mites were transferred to Pera sweet orange plants to verify the transmissibility of the virus back to citrus. Nonviruliferous mites which had no feeding access to diseased tissue were used as controls. Local chlorotic or necrotic spots and ringspots, symptoms of leprosis disease, appeared in most plants tested. Results generated by reversetranscription polymerase chain reaction with primers specific for CiLV-C and by electron microscope analyses confirmed the susceptibility of these plants to CiLV-C.

Geochemical and isotopic evidence for pumping-induced impacts to bedrock groundwater quality in the City of Guelph, Canada.

Groundwater can be a key water resource in urban environments, providing a source of freshwater for community needs. The City of Guelph relies on groundwater for a population of over 130,000 people. Thus, groundwater quality is a critical component of long-term water management. This study assesses the effect of urban, industrial and agriculture activities on groundwater quality using a suite of multidisciplinary methods including geological, hydrological, geochemical, and isotopic tools. Multi-level systems (with depth-discrete ports), conventional well clusters, and municipal production wells were used to monitor hydraulic head and collect groundwater samples. Geochemical and isotopic measurements included redox parameters, major anions and cations, VOC, tritium and δ34S and δ18O in sulfate. Hydraulic head data show vertical gradient profiles characteristic of a multi-layered flow system within a shallow and deep Silurian bedrock aquifer and an intermediate aquitard varying in occurrence. Head loss disappears near production wells, showing enhanced vertical hydraulic connectivity between shallow and deep aquifers, attributed to pumping and long open intervals. Hydrochemical data show no impact of nitrate and high chloride is observed in the shallow and deep aquifer, attributed to seasonal road salt and the underlying aquitard unit, respectively. The aquitard unit also control the high sulfate in the deep aquifer which is supported by the isotope data on sulfate. Facilitated transport of shallow groundwater into the deeper aquifer is supported by the tritium data, showing the presence of recent groundwater throughout the whole depth of the two aquifers in some areas, likely due to the varying aquitard presence and enhanced vertical flow due to proximity from pumping municipal wells and active rock quarry. The results of this research suggest long term implications for groundwater resource management of sedimentary bedrock aquifers, where there is increasing groundwater demand due to population growth and potential for continual water quality degradation.

Role of new Immunophenotypic Markers on Prognostic and Overall Survival of Acute Myeloid Leukemia: a Systematic Review and Meta-Analysis.

Despite technological advances, the prognosis and survival of acute myeloid leukemia (AML) adult patients remain low, compared with other hematologic malignancies. Some antigens detected by immunophenotyping may soon play a significant role in the pathophysiologic, prognostic, and overall survival (OS) rate of AML patients. Therefore, we conducted a systematic review and meta-analysis of PubMed, Scopus, Science Direct, Web of Science, and the Cochrane Library (using PRISMA guidelines). We analyzed 11 studies and 13 antigens, detected through the immunophenotyping of 639 patients. From them, twelve exhibited a negative impact with AML prognosis. The meta-analysis demonstrated a high expression of AML markers, which have been associated with a decrease in survival over 10 months (RR 2.55; IC 95%; 1.49-4.37) and over 20 months (RR 2.46; IC 95%; 1.75-3.45). Knowing that the expression of immunophenotypic markers, which are not used on a routine basis, might be able to influence disease behavior, looks promising. However, they have been associated with a poor prognosis as well as a decrease in survival. This may allow for different chemotherapeutical protocols, including future studies for new therapeutic targets.

The validity and 4-year test-retest reliability of the Brazilian version of the Eating Attitudes Test-26.

In a cross-sectional study conducted four years ago to assess the validity of the Brazilian version of the Eating Attitudes Test-26 (EAT-26) for the identification of abnormal eating behaviors in a population of young females in Southern Brazil, 56 women presented abnormal eating behavior as indicated by the EAT-26 and the Edinburgh Bulimic Investigation Test. They were each matched for age and neighborhood to two normal controls (N = 112) and were re-assessed four years later with the two screening questionnaires plus the Composite International Diagnostic Interview (CIDI). The EAT results were then compared to diagnoses originating from the CIDI. To evaluate the temporal stability of the two screening questionnaires, a test-retest design was applied to estimate kappa coefficients for individual items. Given the prevalence of eating disorders of 6.2%, the CIDI psychiatry interview was applied to 161 women. Of these, 0.6% exhibited anorexia nervosa and 5.6%, bulimia nervosa (10 positive cases). The validity coefficients of the EAT were: 40% sensitivity, 84% specificity, and 14% positive predictive value. Cronbach's coefficient was 0.75. For each EAT item, the kappa index was not higher than 0.344 and the correlation coefficient was lower than 0.488. We conclude that the EAT-26 exhibited low validity coefficients for sensitivity and positive predictive value, and showed a poor temporal stability. It is reasonable to assume that these results were not influenced by the low prevalence of eating disorders in the community. Thus, the results cast doubts on the ability of the EAT-26 test to identify cases of abnormal eating behaviors in this population.

Diversity and Genetic Variation among Brevipalpus Populations from Brazil and Mexico.

Brevipalpus phoenicis s.l. is an economically important vector of the Citrus leprosis virus-C (CiLV-C), one of the most severe diseases attacking citrus orchards worldwide. Effective control strategies for this mite should be designed based on basic information including its population structure, and particularly the factors that influence its dynamics. We sampled sweet orange orchards extensively in eight locations in Brazil and 12 in Mexico. Population genetic structure and genetic variation between both countries, among locations and among sampling sites within locations were evaluated by analysing nucleotide sequence data from fragments of the mitochondrial cytochrome oxidase subunit I (COI). In both countries, B. yothersi was the most common species and was found in almost all locations. Individuals from B. papayensis were found in two locations in Brazil. Brevipalpus yothersi populations collected in Brazil were more genetically diverse (14 haplotypes) than Mexican populations (four haplotypes). Although geographical origin had a low but significant effect (ca. 25%) on the population structure, the greatest effect was from the within location comparison (37.02 %). Potential factors driving our results were discussed.

[Cardiac evaluation in children with suspected heart disease. Preliminary results in 2000 patients]. / Avaliação cardiológica em crianças com suspeita de cardiopatia. Resultados preliminares em 2000 pacientes.

Two thousand consecutive children have been evaluated for suspected heart disease in a 27-month period. The main reasons for referral were: murmur (70%), precordial pain (9.5%), suspicion of arrhythmia (8.5%) and breathless (5%). Five hundred and six (25%) cases did not complete the investigation and the results were not computed. A final diagnosis was obtained based on the reason for referral and the main conclusions were: 1) a high incidence of normality was found: murmur (83%), pain (98%), arrhythmia (97%) and breathless (94%); 2) heart disease is unlikely when other referral reasons were analyzed; 3) 14% of the children were considered abnormal and the necessity of therapeutic procedures was 0.8%. A pediatric cardiology outpatient clinic in a public setting seems to be justifiable in the region, due to the high current demand.

[Incidence of heart defects in Down syndrome]. / Incidência de cardiopatias congênitas na Síndrome de Down.

Eighty-six patients with Down Syndrome were studied with the main purpose of quantifying the incidence of congenital heart defects and the risk of occurrence according to the mothers age. Thirty-eight patients had the cariotypes determined, 35 of them having trissomy of chromosome 21 and translocation in 3 cases. Congenital heart disease was found in 44 (51%) of the patients, the most common one being ventricular septal defect. An important incidence of Fallot's tetralogy was also found (20%). These 86 children were submitted to 41 surgical procedures, most of them on the cardiovascular system. The maternal mean age was 33 -/+ 8.6 years and the estimated risk of Down Syndrome was 1/590, a lower value than the one reported in other studies.

[Congenital rubella syndrome and the occurrence of congenital heart disease]. / Síndrome da rubéola congênita e a ocorrência de cardiopatias congênitas.

Aiming to document the incidence and type of associated congenital heart disease, 20 children affected with the congenital rubella syndrome have been evaluated during a 5 year period, starting 1988. Congenital heart disease was detected in 45% of the cases. Persistent ductus arteriosus was the most frequent finding, followed by ventricular and atrial septal defects. Hearing disturbances occurred in 83% of the 12 cases studied. Ophthalmic lesions appeared in 69% of the 13 cases analysed, congenital cataracts being the most frequent one. An association of 66% was found between ophthalmic and heart lesions. Regarding the nutritional index, 70% of the cases were situated between the 25th and 50th percentile. The relevant incidence of congenital defects and the documentation of an important number of cases in a short period of time point out to a significant prevalence of the syndrome with imperative need improve the vaccination programs.

[Echocardiography in cor triatriatum dexter]. / Ecocardiografia em "cor triatriatum dexter".

"Cor triatriatum dexter" (CTD) is an unusual cyanotic cardiac defect in which the right atrium is subdivided into two distinct chambers due to the persistence of the "sinus venosus" valve. Two patients with CTD ho were evaluated and treatment in 1979 and 1992 are described: the first one, had total anomalous pulmonary venous return to the coronary sinus or "cor triatriatum sinister" as preoperative diagnosis based on M-mode echocardiographic findings. The presence of a membrane inside the right atrium was suspected on cineangiogram. The other one had a preoperative diagnosis of CTD. Anatomic relationships and physiological effects were established by two dimensional and Doppler ultrasonography and confirmed at cardiac catheterization and surgery. High resolution two dimensional echocardiography coupled with Doppler ultrasonography has a definite role in the study of this heart defect.

[Abnormal origin of left coronary artery from pulmonary artery]. / Origem anómala da artéria coronária esquerda a partir da artéria pulmonar.

OBJECTIVE: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA). DESIGN OF THE STUDY: Prospective study of case series between March 1991 and December 1994. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS AND METHODS: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed. RESULTS: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram. CONCLUSIONS: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

[Management of children with heart murmurs. Diagnostic importance of noninvasive complementary tests]. / Abordagem da criança com sopro cardíaco. Importância diagnóstica dos exames complementares não-invasivos.

PURPOSE: To determine the benefits of noninvasive tests in the characterization of heart disease in children referred due to heart murmur. METHODS: Two hundred and thirty three consecutive children were fully examined with the aid of the electrocardiograma (ECG), chest X-ray and echocardiogram (ECHO). The patients were divided in 2 groups according to the initial diagnosis of innocent murmur (n = 23) and pathological murmur (n = 210). A comparison was made between the initial and final diagnosis after the noninvasive tests. Statistical analysis was employed through the qui-square test. RESULTS: The initial diagnosis did not change after ECG. The chest X-ray induced the diagnosis of idiopathic dilatation of the main pulmonary artery in one case and of cardiomyopathy in 8 cases, confirmed in only one. After ECHO, the initial diagnosis of innocent murmur was maintained in 70% of the cases, while 30% had some form of heart disease. In 80% of the pathologic murmur group, the diagnosis did not change after ECHO, while 20% were considered as having an innocent murmur. In the 2 groups together, the concordance index between initial and final diagnosis after ECHO reached 90%. Statistically, a non-significant difference was found between the 2 groups. CONCLUSION: Careful clinical examination is mandatory in the initial evaluation of children with heart murmur. ECG and chest X-ray does not change the initial clinical diagnosis. After ECHO, the diagnosis changing was low (10%), as long as clinical mistakes are eliminated. The initial diagnosis of innocent murmur excludes the necessity of noninvasive tests with a small possibility of error. EKG, chest X-ray and ECHO should be reserved to cases with obvious or persistent suspicious heart disease after clinical examination.

[Quality of life after surgical correction of the aorta coarctation. Retrospective analysis of a group of patients with long-term follow-up]. / Qualidade de vida após correção cirúrgica de coarctação da aorta. Análise retrospectiva de um grupo de pacientes seguidos a longo prazo.

PURPOSE: To report on the long-term results after operation for coarctation of the aorta. METHODS: One hundred and four patients were studied, divided in four groups (G1, G2, G3 and G4), according to age at operation. Data analysed: reoperation, persistent hypertension, residual lesions, left ventricular function and ability index. RESULTS: Reoperation was frequent, mainly in G1 (60%) and G4 (29%). Resting hypertension occurred predominantly in cases operated on after the 10th year of life: 28% (G3) and 29% (G4). Exercise hypertension was found in cases operated on after the 20th year. Residual lesions were frequent: 97%, 98%, 83% and 65% (G1 to G4). Individual functional limitation was uncommon. The ability index was normal in the great majority of the patients (94%). CONCLUSION: Reoperation is frequent, particularly for recoarctation and aortic stenosis. Rest and/or exercise hypertension is common and related to delayed surgery. Aortic residual lesions are frequent. Physical limitation is uncommon. Postoperative follow-up is essential in order to detect late complications, which, usually, do not limit the individual patient.

[Massive pulmonary arteriovenous fistula. A rare, potentially curable cause of hypoxia in the newborn]. / Fístula arteriovenosa pulmonar maciça. Causa rara, potencialmente curável de hipóxia neonatal.

The case of a six-day-old neonate admitted in an emergency situation because of dyspnea and increasing cyanosis is reported. Despite abnormal opacification on the chest X-ray and left ventricular overload on the electrocardiogram and echocardiogram, features compatible with the disease, the diagnosis of massive pulmonary arteriovenous fistula affecting the whole left superior lobe, was made possible only after necroscopic examination.

[Neonatal heart failure and Marfan syndrome]. / Insuficiência cardíaca neonatal e síndrome de Marfan.

We report the case of a neonate admitted to the hospital in the 4th day of life in severe heart failure due to aortic and mitral regurgitation with a largely dilated aortic root. The associated skeletal features involving the superior and inferior limbs as well as the thorax, and joint hypermobility, allowed the clinical diagnosis of Marfan syndrome. Despite favorable initial response to medical therapy, sudden deterioration led to death two weeks after birth. Typical necroscopic findings were confirmed and the case is considered the most severe clinical manifestation possible to be found in this syndrome.

[Left cor triatriatum. Clinical and echocardiographic polymorphism]. / Cor triatriatum sinister. Polimorfismo clínico e ecocardiográfico.

Four cases of cor triatriatum in children aged from 4 days to 12 months are described. In one case isolated classical form of the disease occurred, and in the other it was associated respectively to ventricular septal defect, anomalous pulmonary venous connexion and persistence of left superior venae cava. One child had successful surgical correction, two died before surgery could be attempted and one waits operation. Relevant clinical and investigational data are described and the role of echocardiography as an excellent diagnostic tool is stressed. We conclude that isolated form of cor triatriatum can simulate primary lung disease and when associated to other cardiac anomalies it has an earlier diagnosis due to early referral. Surgical results and prognosis depend not only on associated anomalies but also on early diagnosis.