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A 62-year-old male patient was admitted with regular wide QRS complex tachycardia. After ajmaline administration, the heart rate slowed down disclosing atrial flutter with variable QRS morphologies. Electrocardiography after conversion to sinus rhythm showed narrow QRS complexes. Decremental atrial stimulation during electrophysiological study caused progressive pre-excitation. Spontaneously, typical atrial flutter occurred with pre-excited QRS complexes. Both accessory pathway and atrial flutter were ablated in the same session.

A 54-year-old-woman with narrow QRS tachycardia (heart rate, 210 beats per minute) was admitted to the authors’ hospital. Tachycardia terminated after administration of adenosine. The 12-lead electrocardiogram after conversion to sinus rhythm was unremarkable. During electrophysiological study, tachycardia could be easily induced by programmed atrial stimulation without jump phenomenon. The cycle length was 260 ms. During tachycardia, the atrial activation sequence in the coronary sinus (CS) was distal-to-proximal. However, during decremental ventricular pacing, retrograde conduction showed exclusively proximal-to-distal activation in the CS. What is the underlying mechanism?

The case of a 71-year-old female patient with recurrent supraventricular tachycardia is reported. During the initial electrophysiological study, an orthodromic atrioventricular reentrant tachycardia utilizing a concealed left-sided accessory pathway (AP) was induced. Radiofrequency (RF) ablation via a retrograde aortic approach was unsuccessful. A second ablation attempt 6 weeks later via a transseptal approach using the EnSite Precision three-dimensional (3-D) cardiac mapping system and an irrigated-tip RF ablation catheter also failed to ablate the AP. Therefore, mapping in the coronary sinus (CS) was performed. During right ventricular pacing, the earliest retrograde atrial activation was found in the mid-CS. Irrigated-tip RF ablation for 1.8 s at this region successfully ablated the AP permanently. In complicated cases after failed conventional ablation attempts via a transfemoral or transseptal approach, CS ablation is an effective alternative to percutaneous or surgical ablation of epicardial APs. In such cases, electroanatomical mapping systems may be useful in determining the location of the AP and reducing fluoroscopy time. Furthermore, ablation with irrigated-tip RF catheters can improve the treatment success rate due to larger and deeper lesion formation.

Die postoperative Fazialisparese ist eine gefurchtete Komplikation der Parotidektomie. Der Wasserstrahldissektor scheint ein chirurgisches Verfahren zu sein, bei welchem Gewebe aufgrund ihrer unterschiedlichen Beschaffenheit selektiv unter Schonung wichtiger Strukturen wie Nerven und Gefase getrennt werden konnen. Insgesamt standen 106 mit dem Wasserjet praparierte Nervenaste des N. facialis von 14 Hunden zur Verfugung. Nach einem festgelegten Schema wurden bei der Parotisoperation unterschiedliche Dusen- und Druckparameter angewendet. Im Anschluss an eine postoperative Nachbeobachtungszeit von durchschnittlich 21 Tagen wurden von beiden Seiten jeweils der Nervenstamm, der Stirnast und beide Mundaste gewonnen. Die Gewebepraparation der Nervenresektate erfolgte nach einer Standardmethode fur EM-Praparate. Es finden sich sowohl praparationsabhangige als auch -unabhangige Veranderungen. Je nach dem verwendeten Dusendurchmesser fanden sich eine deutliche Reduktion an normal myelinisierten Nervenfasern, ein deutlicher Nervenfaserverlust sowie eine ausgepragte Fibrose. Es scheint weder der Dusendurchmesser (120 oder 150 μm) noch die Druckstarke (40, 60 oder 80 bar) eine entscheidende Rolle bei der Parotidektomie mittels Wasserstrahldissektor zu spielen. Vielmehr scheint zum einen die Praparationstechnik, namlich eine tangentiale vs. senkrechte Strahlenfuhrung, sowie andererseits auch die unterschiedlich lange Applikationszeit fur die nervalen Schadigungen verantwortlich zu sein. Wird jedoch ein groser Dusendurchmesser von 200 μm genommen, so kommt es – unabhangig von der angewandten Praparation und Applikationszeit – regelmasig zu einer unterschiedlich stark ausgepragten Schadigung der Nervenfasern.

Erste Untersuchungen zum Einsatz des Wasserjets im Rahmen der Parotischirurgie haben am Tiermodell zeigen konnen, dass es je nach verwendeten Dusendurchmessern und Druckstarken zu unterschiedlichen morphologischen Veranderungen mit und ohne Auswirkung auf die klinische Funktion des N. facialis kommen kann. In einer weiteren Untersuchung sollten die histomorphometrischen Daten der mittels Wasserjet praparierten Nervenfasern erhoben werden und in Bezug zu den verwendeten Dusendurchmessern und Druckstarken gesetzt werden. Insgesamt standen 102 Nervenpraparate von 14 Hunden der Rasse Beagle, welche im Rahmen einer vorangegangenen Studie mittels eines Wasserstrahldissektors mit unterschiedlichen Dusendurchmessern und Druckstarken parotidektomiert worden waren, zur Auswertung zur Verfugung. Nach einem durchschnittlichen Beobachtungszeitraum von 21 Tagen mit Dokumentation der klinischen Funktion des N. facialis erfolgte die Entnahme der Nervenpraparate. Es erfolgte dann die Bestimmung der Faseranzahl und der Faserdurchmesser der einzelnen Fazialisaste. Alle Nervenaste, die mit einem gleichen Dusendurchmesser dargestellt wurden, zeigen ungeachtet der unterschiedlichen Dusenstarken eine identische Summenhaufigkeit der Faserdurchmesser der mit einem Dusendurchmesser von 120 und 150 μm praparierten Nervenaste. Alle mit einem Dusendurchmesser von 200 μm praparierten Nervenaste hingegen zeigen morphologische und klinische Auffalligkeiten. Sie wiesen, bezogen auf die Verteilung ihrer Faserdurchmesser, deutliche Unterschiede zu den mit einem Durchmesser von 120 und 150 μm praparierten Fasern auf. Insgesamt zeigt sich ein im Nervenverlauf kleiner werdender Faserdurchmesser. Nach den hier vorliegenden Ergebnissen scheint es eine Verschiebung von groseren Nervenfaserdurchmessern im Stamm zu kleineren Durchmessern in den Terminalasten hin zu geben. Dieses Phanomen ist bislang in der Literatur noch nicht beschrieben. Es scheint jedoch nicht durch den Einfluss der Wasserstrahltechnik bedingt zu sein. Eine eindeutige Klarung der Frage, wie viel prozentualer Anteil der intakten Nervenfaserstruktur nach einer Schadigung vorhanden sein muss, um noch eine Funktion zu gewahrleisten, lies sich nicht herbeifuhren. In unserer Studie reichten bei einem durch den Wasserstrahl geschadigten Nerven 22% der ursprunglichen Nervenfaseranzahl aus, um eine intakte Funktion aufrechtzuerhalten.

Neuronal intestinal dysplasia (NID) is wellknown, but its definition is a topic of debate. The histopathological diagnosis of NID is based on traditional enzyme-histochemical methods such as the acetylcholinesterase and dehydrogenase reaction on native cryosections. In this study, we have investigated the enteric nervous system in whole mount preparations of resected intestinal segments affected by NID of the plexus submucosus (type B). The plexuses of the tunica mucosa and tunica submucosa were visualized by immunohistochemical methods using a polyclonal antibody to protein gene produce 9.5 (PGP 9.5). PGP 9.5 is a novel general cytoplasmatic marker specific for the nervous system. The morphology of the plexuses is revealed in full, making possible changes easily discernible. Known pathological findings of the NID can be identified and judged more precisely with this method. Numerous enlarged nerve trunks run within the tunica submucosa and tunica mucosa. Hyperplastic ganglia with an unusually high nerve cell number in the tunica submucosa can be demonstrated as well as heterotopic nerve cells in the tunica mucosa.

EDITORIAL COMMENT: Results of obstetric practice are conventionally assessed by consideration of perinatal and maternal mortality rates, rates of intervention in labour (induction, epidural analgesia), rates of operative procedures for delivery (episiotomy, forceps, Caesarean section) and rates of postpartum complications (retained placenta, postpartum haemorrhage). Other important considerations are physical and emotional morbidity and whether or not the woman and her partner are pleased with the birthing experience and their birth attendants. The editorial committee wishes to request readers to provide information concerning the long-term emotional results of the male partner's decision to be present at the birth of his child since such data is not available and yet is relevant to the advice given to women regarding the partner's role during parturition. This paper reports a marvellous perinatal mortality rate for births in a birth centre. Indeed the editor makes the prediction that this figure of less than 1 death per 1,000 births for women accepted for delivery in a Birth Centre, including those with intrauterine death diagnosed when the woman was admitted in labour, will stand as a record, since this rate is less than 10% of that for the state of Victoria as a whole (9.7 per 1,000 births in 1990). The results according to the method of delivery are also exemplary. It should be noted however, that 19 fetal deaths in utero occurred in the 889 women excluded from the group because of antenatal complications, and the authors do not provide information regarding neonatal deaths in this group or the number, if any, of these women admitted in labour with an intrauterine death. The data provided indicates that the perinatal mortality rate in the 5,365 women initially booked for delivery in the Birth Centre was at least 4.3 per 1,000 (23 in 5,365). Authors' Response: In addition to the 4 perinatal deaths in patients who presented to the Birth Centre in labour, and the 17 intrauterine deaths listed in table 4, there were 15 other deaths (9 stillbirths, 6 neonatal deaths) in the patients excluded antenatally i.e. the perinatal mortality rate for the original series of 5,365 women was 6.7 per 1,000 births. Summary: In reviewing the first 10 years experience of the Royal Women's Hospital Family Birth Centre (FBC), we examined the outcomes of pregnancy and labour in a group of women who requested alternative birthing care and who were identified antenatally as being a ‘low-risk’ population. This study is a retrospective analysis of 5,365 women booked with the birth centre between 1980 and 1989. Over 16% of women developed antenatal complications precluding further care there, while a further 16% developed complications in labour requiring transfer out to conventional labour wards. Thus 67% of those originally booked delivered in the FBC. The instrumental delivery rate was 11%, and the Caesarean section rate was 4%. Of the women who delivered in the FBC, 3.1% had a postpartum haemorrhage and 1.8% required manual removal of placenta. Approximately 4% of babies born in the FBC required some resuscitation, and 0.8% needed admission to the neonatal nursery. Two perinatal deaths occurred in women admitted in labour to the FBC with a live baby, whilst 2 other women presented in labour with a fetal death in utero (perinatal mortality 0.89 per 1,000).

Contents Catheters were surgically placed in the uterine artery and vein of four control and four dexamethasone (DXMS)-treated cows on days 248 or 249 of gestation; at the same time the corpus luteum was removed and all animals were treated with 10 mg chlormadinone acetate i.m. daily to maintain pregnancy. After one day of blood sampling which began on day 250, animals received either 20 mg DXMS crystalline suspension i.m. or only the vehicle solution. Blood sampling was then continued for five additional days. Plasma was assayed for unconjugated estrone (E1), progesterone (P4), and pregnenolone (P5). Concentrations of El were higher in the venous samples (p < 0.02) and increased over time (p < 0.02). There was a site x time interaction (p < 0.05) and a significant effect of DXMS-treatment on the linear component (p < 0.02) of the slope values for the El concentrations for both sampling sites. Concurrently, there was an effect of time on P4 concentrations (p lt; 0.01), the venous P4 concentrations were higher (p < 0.01), and there was also a site x time interaction (p < 0.01) but not treatment effect. There was no significant effect on concentrations of P5 between treatment goups or sampling sites. It is concluded that DXMS activates the synthetic system(s) involved in production of estrone in the cow during late pregnancy. This change in estrone synthesis occurred at an increasing rate during the 5 day sampling period. The data are consistent with the hypothesis that the placenta must be capable of utilizing precursors in the cholesterol or pregnenolone group for estrone synthesis and that the major pathway could be the delta-5 pathway. Inhalt: Veranderungen in der placentaren Hormonsekretion beim Rind nach Behandlung mit Dexamethason. Bei insgesamt 8 Kuhen wurden am 248./249. Tag der Trachtigkeit Katheter in die Vena und Arteria uterina eingelegt, gleichzeitig wurde das Corpus luteum entfernt und zur Aufrechterhaltung der Graviditat wurden 10 mg Chlormadinonacetat taglich wahrend der gesamten Versuchsdauer i.m. verabreicht. Nach einer ersten Blutentnahmeperiode am Tag 250 erhielten jeweils 4 Tiere entweder 20 mg Dexamethason (kristalline Suspension) bzw. das Vehikel (Kontrollguppe) i.m. verabreicht. Die Blutentnahmen erfolgten uber weitere 5 Tage, erfast wurde der Verlauf von freiem Estron, Progesteron und Pregnenolon. Die in der Vena uterina gemessenen Estronkonzentrationen lagen jeweils hoher (p < 0,02) als in der entsprechenden Arterie und stiegen bis zum Ende des Experiments an (p < 0,02). Weiterhin zeigte sich eine Interaktion zwischen dem Ort der Blutentnahme und dem Zeitpunkt (p < 0,05), der Anstieg der Estronkonzen-trationen nach der Behandlung mit Dexamethason war – bezogen auf die lineare Komponente – sigifikant erhoht (p < 0,02). Fur P4 ergab sich ein deutlicher Abfall (p < 0,01), wobei in der Vena uterina stets hohere Werte gemessen wurden als in der Arteria uterina (p < 0,01). Auch hier war eine Interaktion zwischen dem Zeitpunkt und dem Ort der Blutentnahme gegeben (p < 0,01), allerdings konnte ein Behandlungs-effekt nicht dargestellt werden. Fur Pregnenolon ergaben sich keine Unterschiede zwischen Arteria und Vena uterina sowie den Behandlungsgruppen. Die Ergebnisse zeigen, das eine einmalige Behandlung mit Dexamethason zu einer zunehmenden Steigerung der Estronproduktion fuhrt, im Hinblick auf die unveranderte Progesteronsekretion wird geschlossen, das dabei eher der Delta-5-Syntheseweg zugrundeliegen konnte und das die entsprechenden Precursoren auf der Ebene des Cholesterins oder Prepenolons zu suchen sind.

PURPOSE: Several alterations of the enteric nervous system have been described as an underlying neuropathologic correlate in patients with idiopathic slow-transit constipation. To obtain comprehensive data on the structural components of the intramural nerve plexus, the colonic enteric nervous system was investigated in patients with slow-transit constipation and compared with controls by means of a quantitative morphometric analysis. METHODS: Resected specimens were obtained from ten patients with slow-transit constipation and ten controls (nonobstructive neoplasias) and processed for immunohistochemistry with the neuronal marker Protein Gene Product 9.5. The morphometric analysis was performed separately for the myenteric plexus and submucous plexus compartments and included the quantification of ganglia, neurons, glial cells, and nerve fibers. RESULTS: In patients with slow-transit constipation, the total ganglionic area and neuronal number per intestinal length as well as the mean neuron count per ganglion were significantly decreased within the myenteric plexus and external submucous plexus. The ratio of glial cells to neurons was significantly increased in myenteric ganglia but not in submucous ganglia. On statistical analysis, the histopathologic criteria (submucous giant ganglia and hypertrophic nerve fibers) of intestinal neuronal dysplasia previously described in patients with slow-transit constipation were not completely fulfilled. CONCLUSION: The colonic motor dysfunction in slow-transit constipation is associated with quantitative alterations of the enteric nervous system. The underlying defect is characterized morphologically by oligoneuronal hypoganglionosis. Because the neuropathologic alterations primarily affect the myenteric plexus and external submucous plexus, superficial submucous biopsies are not suitable to detect these innervational disorders.

Certain reconstructive procedures, like auricular reconstructions, require thin and well-vascularized skin. The aims of this study were to analyze if the increased survival of expanded skin flaps was due to morphologic changes of the dermis, if thinning of short-time expanded skin was possible without harm to the microcirculation and if tissue selective cutting methods could be used to resect subcutaneous fat without damaging its vessels. Eighty-two 200-ml expanders were implanted into the trunk regions of 26 beagles and filled immediately with sterile saline. In the first series of experiments, the expansion was terminated after intervals of 0.5–5 weeks and dermal vessels were analyzed morphometrically. In the second series the expanded flaps were raised after 2 weeks and thinned solely surgically or with the additional use of an ultrasonic knife or with cutting by water jet. In contrast to sham flaps, the expanded skin showed only very few areas of necrosis and these were located superficially in most cases. The relative volume of the dermal vessels and their quantity showed a significant increase after the expansion. Additionally, the subcutaneous tissue could be thinned down to 0.4 mm with the water-jet-cutter. Findings demonstrated that the method used could create a well-vascularized skin flap of minimal thickness that could be very helpful for special reconstructive procedures.

Analysis is made of fetal growth in 563 twin pregnancies. The birth-weight of a twin is affected by the duration of pregnancy and zygosity. Intrauterine growth and weight is the same as a singleton pregnancy up to a gestational age of 32 weeks. After this stage fetal growth slows markedly. The growth curves of both twins are similar with an increasing tendency towards growth retardation in twin 2 after 39 weeks' gestation. Intrauterine growth retardation, as represented by the 10th percentile line, for twin 1 joins 1,094g at 31 weeks, 1,836g at 36 weeks and 2,428g at 40 weeks' gestation. The corresponding figures for twin 2 are 1,131g, 1,875g and 2,337g respectively.

Thiamine is important for oxidative metabolism, and B1 deficiency is thought to give rise to polyneuropathies. A group of male Wistar rats (n = 15) received a vitamin B1 deficient diet (group-a), and the pair fed control group (n = 20, group-b) received a normal diet with no vitamin deficiency. A second control group (group-c) was fed unrestrictedly with a standard diet (n = 19). All animals were examined for 25 weeks. The sensory nerve conduction velocity, the compound radicular, spinal and brain stem responses and the SEP were derived for tail and hind paw stimulation. The examination was repeated at 6-week intervals. There was no difference in nerve conduction between group-a and -b, but for both groups the conduction velocity was significantly slower than in group-c. The SEP latencies were significantly increased in group-a compared with group-b and also with group-c. The spinal and cerebral latencies were delayed in group-a. The diameters of myelinated nerve fibres were decreased in group-a compared with group-b, and in group-b compared with group-c. The results indicate that a specific polyneuropathy exists as a result of B1 deficiency, and that the sequelae of the lack of thiamine are pronounced in the CNS.

– Two groups of alcoholics (30 patients each) – identified by the MALT score – were examined. Clinical and laboratory investigations showed no connection between thiamine, riboflavin, or Vitamin B6 deficiency and development of the polyneuropathy. Neither the polyneuropathy nor the diminished sensory conduction velocity were related to malnutrition. The relation between the duration of alcoholism and symptoms of polyneuropathy was highly significant in one group. The neurotoxicity of ethanol was confirmed in an experiment with rats.

The clinical and pathological features of oligohydramnios associated with severe pulmonary hypoplasia are described in 10 infants without renal anomalies. In 8 patients the condition was associated with prolonged premature rupture of the membranes at 16 and 36 weeks of gestation in a study of 244 patients (3.3%). Seven of the infants died of respiratory failure within 24 hours of delivery; the other infant survived. In the remaining 2 patients with severe oligohydramnios at term, but unassociated with premature rupture of the membranes, both infants succumbed. Problems with resuscitation should be anticipated in pregnancies complicated by prolonged leakage of amniotic fluid or oligohydramnios, and pulmonary hypoplasia should be recognized as a cause of respiratory distress. Apart from the ultrasonic predelivery confirmation of normal kidneys to exclude Potter's syndrome it is recommended that ultrasonic assessment of thoracic cage volume should be made before delivery.

To determine the effect of short-term administration of diclofenac-colestyramine on glomerular filtration rate (GFR), renal plasma flow (RPF) and urinary excretion of prostanoids in patients with type-2 diabetes without and with impaired renal function.In the randomised, single-blind, placebo-controlled, two-period crossover study, 32 patients with type-2 diabetes (group 1: 16 patients without impaired renal function, creatinine clearanceor =80 ml/min and group 2: 16 patients with impaired renal function, creatinine clearance 30-79 ml/min) received 140 mg diclofenac-colestyramine (corresponding to 75 mg diclofenac sodium) or placebo twice a day on days 1 and 2 and once on day 3 with a wash-out period of 6 days between the two periods. GFR was assessed using both measurement of creatinine clearance and calculation of inulin clearance and RPF was assessed using calculation of para-aminohippurate (PAH) clearance after the short-term administration on day 3. Urinary excretion of prostanoids (PGE(2), PGE-M, 6-keto-PGF(1alpha), 2,3-dinor-6-keto-PGF(1alpha), TxB(2), 2,3-dinor-TxB(2) and 11-dehydro-TxB(2)) were measured before and after drug intake.Comparison with placebo showed no effect of diclofenac-colestyramine on creatinine, inulin or PAH clearance ( P0.05) in patients with type-2 diabetes either without or with impaired renal function. The differences in creatinine, inulin and PAH clearance between the two groups of patients were not influenced by diclofenac-colestyramine. Urinary excretion of PGE(2), PGE-M, 6-keto-PGF(1alpha), 2,3-dinor-6-keto-PGF(1alpha), TxB(2), 2,3-dinor-TxB(2) ( P=1.89) and 11-dehydro-TxB(2) was significantly reduced by diclofenac-colestyramine.These results indicate that proven non-specific cyclooxygenase inhibition by short-term administration of diclofenac-colestyramine did not affect renal haemodynamic function (GFR, RPF) in patients with type-2 diabetes either without or with impaired renal function.