[Whether or not to perform an early endoscopy following ingestion of potentially caustic agents - a retrospective longterm analysis in a tertiary referral institution]. / Wann sollte eine frühe endoskopische Inspektion bei Verletzungen des oberen Gastrointestinaltrakts nach Ingestion von potenziell ätzenden Substanzen und anderen Noxen erfolgen? - Eine retrospektive 13-Jahres-Analyse in einem tertiären Haus der Maximalversorgung.

BACKGROUND: The optimal clinical management of patients following ingestion of potentially caustic lesions is still undetermined. In particular, the indication for early upper GI endoscopy in this context remains unclear. PURPOSE: To draft recommendations regarding the use of early upper GI endoscopy following hospital admissions of patients after ingestion of potentially caustic agents. METHODS: For this purpose, a retrospective cohort study of patients treated for ingestion of potentially caustic substances during a 13 year-period at the university hospital of Berne was performed. RESULTS: In total, 61 patients with acute ingestion of potentially caustic substances were identified. Overall mortality was 5 %. 11/61 patients had to be admitted to the intensive care unit. Most ingestions were performed in suicidal intention (62 %). In 53 % of these patients, a combined ingestion of several substances occurred. In 33 % of patients, an early upper GI endoscopy was performed within 24 hours after ingestion. The degree of burn depended upon the hazard potential of the respective substance. In patients with ingestion of low risk substances, upper GI endoscopy was only performed when additional risk factors were present. CONCLUSION: Based upon the results of the present study, ingestion of potentially caustic agents requires an individualized strategy whether or not to perform early endoscopy.

Exercise-induced hypertension in the arms due to impaired arterial reactivity after successful coarctation resection.

Exercise-induced hypertension of the arms is a well-known late complication after coarctation repair. Residual narrowing at the anastomosis site as well as abnormalities of the precoarctation arterial system may be the cause of this problem. Blood pressure response to exercise and flow-mediated arterial dilatation of the arms and legs were studied in 29 young adults after successful coarctectomy in childhood and compared with 13 control subjects. Peak exercise systolic blood pressure was significantly higher in patients than in control subjects: 238 versus 199 mm Hg (p = 0.007). Both groups had a positive systolic arm-leg gradient during exercise: 59 versus 37 mm Hg (p = 0.05). Flow-mediated dilatation of the brachial artery was significantly reduced in patients compared with that in control subjects: 4.2% (range 0% to 9.4%) versus 9.4% (range 3.7% to 16%) (p < 0.0001). Flow-mediated dilatation of the femoral artery was similar in both groups. Dilatation of the brachial artery was inversely correlated to peak exercise systolic pressure in the study patients (r = -0.427, p = 0.02). A positive arm-leg exercise gradient partly represents physiologic circulatory adaptation to ergometry and is therefore not appropriate for evaluation of residual narrowing. Exercise-induced hypertension of the arms late after coarctation repair is caused by impaired arterial reactivity, which results from structural or functional abnormality, or both.

Effects of morphologic restenosis, defined by MRI after coarctation repair, on blood pressure and arm-leg and Doppler gradients.

Ten years after coarctation repair, 36 adolescents and young adults were studied in order to evaluate the relationship of anatomy at the resection site to blood pressure and arm-leg and Doppler gradients. The patients underwent magnetic resonance imaging (MRI), exercise testing, and continuous wave (CW) Doppler echocardiography. On MRI, residual narrowing at the resection site was measured as 1-(phi anastomosis/ phi descending aorta) and expressed as percent stenosis. Residual stenosis on MRI was negatively correlated with the leg pressure at rest (P = 0.0003) and during exercise (P = 0.002). Residual stenosis correlated positively with the arm-leg gradient at rest (P < 0.0001) and during exercise (P < 0.0001) and with the peak CW Doppler gradient across the anastomosis (P < 0.0001). However, residual stenosis was not related to the systolic blood pressure of the arm at rest or during exercise. The systolic arm pressures did not differ between patients with residual stenosis of less than 30% (group I), patients with residual stenosis of equal to or greater than 30% but less than 45% (group II), and patients with residual stenosis of equal to or greater than 45% (group III). In conclusion residual anatomic stenosis influences blood pressure in the legs, the arm-leg gradient, and the Doppler gradient across the anastomosis. Arm hypertension late after coarctation repair seems not to be related to residual stenosis, and the benefit of reintervention in these patients remains questionable.

[Pediatric cardiological emergencies]. / Kinderkardiologische Notfälle.

Emergencies in pediatric cardiology are heart failure, cyanosis and rhythm disturbances. The signs of heart failure are tachycardia, tachypnea and hepatomegaly. The therapy consists of oxygen, diuretics and digoxin. Occasionally, intubation with mechanical ventilation and intravenous catecholamines are needed. Cyanosis is often the only sign of a severe heart malformation, and prompt hospitalization is mandatory. Oxygen and warm environment is important during transport, correction of a possible metabolic acidosis and prostaglandin infusion are done in the hospital. Beyond the newborn period, so-called cyanotic spells are seen, particularly in tetralogy of Fallot. In supraventricular tachycardia, vagal manoeuvres can be tried first, if not successful, intravenous adenosine or electroconversion will restore sinus rhythm. In the older child, intravenous isoptin can be given. Slow heart rates from total AV block or sinus node affection are treated with atrophic, isuprel or electrical pacing.

Effects of hypoxia on distribution of cardiac output and organ blood flow in the rabbit. Regional vascular response to hypoxia.

The hemodynamic responses of various vascular beds in the systemic circulation to prolonged moderate hypoxia were studied in the rabbit using the radioactive microsphere method. Although cardiac output remained unchanged, there was a redistribution of blood flow in which blood was mainly diverted from the kidneys to provide greater supply to heart, brain and skeletal muscle. These regional adjustments are similar to those seen after low cardiac output due to hemorrhage or endotoxic shock.

Complete atrioventricular septal defect and Ebstein anomaly.

The newborn reported here presented with congestive heart failure and cyanosis on the first day of life. Echocardiographic examination revealed complete atrioventricular septal defect and Ebstein anomaly, a rare combination that has not been previously reported in the literature.

Doppler echocardiography during exercise to predict residual narrowing of the aorta after coarctation resection.

Blood pressure measurements and Doppler echocardiography at rest and during exercise were performed in 36 patients at an average 17 years after coarctation resection. Interest focused on the study of Doppler systolic and diastolic gradients and half-times during exercise. Blood pressure gradients and Doppler values were compared with the degree of narrowing at the site of the anastomosis measured by magnetic resonance imaging. A systolic half-time of >110 ms together with a diastolic gradient of >/=17 mmHg on exercise Doppler sonography predicted a residual isthmic narrowing of >30%. We propose the use of this noninvasive method for identifying patients with narrowing of >30% at the site of the anastomosis after coarctation resection. In these cases evaluation by an imaging technique is necessary to confirm the need for surgery.

Symptomatic atrial septal defect in the neonate and infant.

Atrial septal defect, secundum type, is rarely diagnosed and seldom produces symptoms in infancy. 7 patients, aged between 2 weeks and 8 months, who developed congestive failure, are presented. 6 of them had an atrial LR-shunt documented at cardiac catheterization. 1 diagnosis was made at post mortem in the only infant who died. The clinical signs of an ASD do not vary from those normally found in the older child; the causes for early failure are probably rapidly decreasing pulmonary vascular reistance and disturbances of left ventricular compliance. 6 infants improved with conservative or no treatment, although spontaneous closure or significant diminution of the shunt did not occur. Surgical closure can be deferred to a later optimal age for operation. ASD secundum type should be considered as a cause of heart failure in the neonate and infant.

Regional vascular responses to asphyxia in the rabbit.

Organ blood flow was measured in eight spontaneously breathing male New Zealand white rabbits exposed to a 50 min period of asphyxia. The results were compared with eight control animals. Cardiac output and arterial pressure did not change. There was increased flow to the heart, brain and diaphragm. Flow to the kidneys and adipose tissue was reduced. Flow to the gastro-intestinal tract, liver, skeletal muscle and carcass was unchanged. Prolonged moderate asphyxia produces preferential blood supply to vital organs and maintains flow to the skeletal musculature and the gastro-intestinal tract; their blood supply is diverted mainly from the kidneys. These changes are similar to those seen in haemorrhagic and endotoxic shock in the rabbit.

Cognitive task influence on relative hemispheric motor control: mouth asymmetry and lateral eye movements.

While strictly verbal cognitive tasks showed a strong left-hemisphere dominance, the presence of visualization and emotion in cognitive tasks resulted in increased involvement of the right hemisphere in motor control of speech as measured by mouth asymmetry. Spontaneous smiles showed right-hemisphere dominance. Lateral eye movements showed an unexpected shift to left gaze during speech which may suggest a dual task interference between speech and gaze motor control.

Successfully treated mitral valve endocarditis in a neonate.

We report on a newborn with severe congestive heart failure where echocardiography was leading to the correct diagnosis and the treatment. Endocarditis in the newborn is a rare disease, and the diagnosis is possible from the echocardiographic demonstration of vegetations. It is therefore important to search for vegetations in the very ill newborn with cardiac symptoms, in order to start early antibiotic treatment independently of positive cultures and to avoid the usual fatal outcome of this disease.

Hypernatraemic dehydration revisited.

After discussing earlier concepts of hypernatraemic dehydration, experiments on infantile mini-pigs are reported. After giving osmolar NaCl and NH4Cl solution, dehydration with chloride acidosis was produced and then rehydration was started for 24 h. From the findings the conclusion was drawn that in hypernatraemic dehydration cerebral lesions are not primarily due to an overall impairment of brain blood flow and that blood pressure is a misguiding criterion of fluid loss and circulatory assessment.

Reference values of various blood constituents in young minipigs.

In the Göttinger minipig, the reference values of 18 parameters in whole blood or plasma were determined. The results are expressed both as the mean value and +/- 2 SD presuming a symmetrical normal distribution and as the median value with the corresponding range. For most blood constituents, the results of the two modes of calculation were similar. Comparison of the values from young minipigs with those from children shows that these animals are well suited in this respect for experimental work related to human medicine.

Arm-leg pressure gradients on late follow-up after coarctation repair. Possible causes and implications.

Seventeen years after coarctation repair, 36 patients were studied by magnetic resonance imaging and exercise testing to measure residual anatomical stenosis and hormonal response to exercise, and to evaluate their effect on arm-leg gradients and on exercise hypertension. The systolic arm pressure, leg pressure and arm-leg gradient were measured at rest and during exercise. Active renin and catecholamines were measured in the plasma at rest and after peak exercise. On magnetic resonance imaging 18 patients had residual stenosis of less than 30% (group I) and 18 had residual stenosis of equal to or more than 30% (group II). At peak exercise, the arm pressure was 235 (133-296) mmHg in group I and 241 (157-286) mmHg in group II (ns), the leg pressure was 138 (111-173) mmHg in group I and 114 (75-154) mmHg in group II (P = 0.002). The adrenalin increase from rest to exercise was 32.7 +/- 9.1 pg.ml-1 in the patients with exercise hypertension and 3.1 +/- 4.7 pg.ml-1 in the patients who remained normotensive during exercise (P = 0.02). In conclusion, residual anatomical stenosis leads to a pressure drop in the legs, which influences the arm-leg gradient. Arm hypertension is not related to anatomical narrowing but to interaction of enhanced sympathetic nerve activity and structural and functional abnormality of the precoarctation vessels.

Aneurysm of the nonpatent ductus arteriosus in the newborn.

Aneurysm of the nonpatent ductus arteriosus in the newborn is a rare, but potentially fatal condition. Of reported ductal aneurysm up to 1969, diagnosis was made at autopsy only. We report here to our knowledge for the first time on a two week old infant with correct preoperative angiographic diagnosis followed by a successful surgical cure.

Cardiomyopathy in respiratory chain disorders.

Disorders of mitochondrial oxidative phosphorylation may disturb cardiac energy metabolism and cause cardiomyopathy. Twenty one cases from the literature and one further patient with cardiomyopathy due to biochemically defined respiratory chain defects were reviewed for clinical course, morphology, and pathophysiological mechanisms of the cardiomyopathy. All cases showed concentric hypertrophy of the myocardium without an outflow tract obstruction. In most patients the cardiomyopathy was diagnosed early in infancy and showed rapid deterioration with death before the age of 2 years. Hypertrophy of the myocardium appears to result from swelling of the cardiomyocytes caused by accumulation of mitochondria and by morphologically abnormal megamitochondria.

Validation studies for the use of the microsphere method in cats and young minipigs.

Radioactive microspheres are suitable for measuring cardiac output, its distribution and organ blood flow if certain criteria are met. Cardiac output may be determined with the reference flow method if microspheres do not recirculate. In case 10 micron microspheres were extracted completely by the lungs. The use of microspheres for the determination of cardiac output is therefore not limited by recirculation of microspheres down to this size. Under baseline conditions we found no preferential streaming with 50 micron spheres in young minipigs and with 25 and 15 micron spheres in cats At high cardiac output values induced by the administration of 0.4 mg/kg of Dihydralazine in cats, 25 micron but not 15 micron microspheres showed a small, non significant tendency to stream preferentially into the upper body. Thus, under rapid flow conditions 15 micron microspheres may be preferable to larger ones from the rheological point of view. Under baseline conditions the distribution of cardiac output to a wide range of organs was very similar when comparing 25 and 15 micron microspheres in cats and 50 and 15 micron microspheres in minipigs, whereas 10 micron microspheres were poorly extracted by most organ in cats. 15 micron microspheres were found to be suitable for the determination of cardiac output and its distribution in both species provided that bronchial and arteriovenous shunt flows can be neglected.

Hemodynamic changes in hypernatremic dehydration in the mini-pig.

Hypernatremic dehydration with metabolic acidosis and azotemia was experimentally induced in the mini-pig by feeding a hypertonic NaCl and NH4Cl solution wit nasogastric tube. After a loss of 19% of initial body weight within 32 hours, the following hemodynamic changes were observed: the heart rate rose, the arterial blood pressure was maintained, but cardiac output fell to 80% of its initial value. There was a redistribution of this lowered cardiac output with unchanged blood flow to heart, brain, adrenals and skeletal muscle. The flow to these vital organs was diverted to selective vasoconstriction of spleen, pancreas, gastrointestinal tract and kidneys. Quantitatively the contribution from the latter two organs was the most important.

Influence of rehydration on organ blood flow after hypernatremic shock in the unrestrained young minipig.

Hypernatremic shock was produced in the minipig by feeding hyperosmolar solutions, which led to osmotic diuresis and dehydration. Weight loss was 14%, serum values (in mmol/L) were, for Na, 168; urea, 12.1; bicarbonate, 10.5; and pH 7.25 (mean values). Cardiac output was reduced by 51%, arterial pressure was unchanged (-5.1%); organ blood flow, measured with radioactive microspheres, was as follows: heart, -56%; brain, -35%; gastrointestinal tract, -60%; and kidneys, -57%. Intravenous rehydration for 24 h normalized weight, serum electrolytes, and pH; but had little effect on cardiac output and organ blood flow. Even prolongation of fluid therapy to 48 h did not restore the circulatory changes, which showed an arterial pressure of +4.3%; cardiac output, -31%; and flow to heart, -21%; brain, -24%; gastrointestinal tract, -30%; and kidneys, -47%. This pattern of diminished cardiac output, normal arterial pressure, and reduced organ blood flow not only in the splanchnic organs but also in heart and brain is similar to the hemodynamic response to vasopressin. Increased vasopressin release probably plays an important role after rehydration in hypernatremic shock.