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Fungal endocarditis, a rare and lethal infection, is aetiologically connected with Candida and Aspergillus species. Among these two agents, Candida is a common nosocomial infection with increasing rates over the last years and mortality up to 40% in cases of systemic candidiasis. In the present paper, we describe the case of a 58 year old woman with metastatic breast cancer under palliative chemotherapy who was hospitalized for recurrent episodes of fever due to fungal endocarditis of the implantable venous access port. Such cases may elude the attention of the physician and need to be taken into account especially in oncologic patients with implantable devices under chemotherapy regimens. The treatment of Candida endocarditis can be difficult because of the formation of biofilms on prosthetic devices. The prognosis of these patients may be ameliorated with the combination of fungal and invasive treatment.

We report three cases of patients with blunt thoracic trauma, who underwent transesophageal echocardiography (TEE) because of high index of clinical suspicion for acute traumatic aortic syndrome. TEE revealed three different locations of aortic injury one of which was not diagnosed with aortography.

Backround: Prolongation of QT dispersion (QTD), defined as the difference between maximum and minimum QT intervals on surface ECG, has been proposed as a noninvasive arrythmogenic marker. The aim of this study was to estimate the value of QTD in identifing patients susceptible to ventricular fibrillation or ventricular tachycardia (VF/VT) after an acute myocardial infarction (AMI) and to evaluate the behavior of QTD in relation to the thrombolytic therapy. Methods: We studied 108 consecutive patients with AMI. All patients had a 12-lead surface ECG recorded upon admission and a second ECG 24 hours later. QT interval was measured from the onset of Q to the end of T in each of 12 standard ECG leads. QTD was the difference between the longest and shortest values of QT. All QTD measurements were corrected for heart rate (QTcD) using QTc values according to Bazzet formula. Results: Fifteen patients (13.8%) developed VF/VT in the first week after AMI (group 1A) and 93 patients (86.2%) did not have VF/NT (group 1B). QTD and QTcD values were significantly greater in group 1A in comparison to group 1B on admission and 24 hours later. Sixty-five patients (60%) received intravenous thrombolysis in the acute phase of AMI (group 2A) and 43 patients (40%) did not (group 2B). No significant difference in QTD and QTcD was observed in the first ECG on admission between the two groups. Conversely, QTD and QTcD were lower in group 2A patients in the second ECG 24 hours after admission. Conclusions: These results provide evidence that increased values of QTD are correlated well with occurrence of malignant ventricular arrhythmias after acute myocardial infarction while lower values associated with the thrombolytic therapy. A.N.E. 1999;4(1):35–38

This study was undertaken to determine whether adaptations to short-term exercise training after myocardial infarction, could affect the response of heart rate, blood pressure and double product at submaximal workload, and the behavior of electrocardiographic ST segment depression. We studied 60 patients (group A) who underwent a modest level exercise training for 3 months and 40 patients (group B) who did not participate in this program. All these subjects were involved in the trial 1 week after discharge from the hospital. Submaximal treadmill stress test was performed after the 3-month period. The stress test duration was longer (p < .01), heart rate (p < .001), systolic blood pressure (p < .01) and double product (p < .01) at submaximal workload were lower and the onset of ST depression of 1 mm was delayed (p < .01) in group A. In conclusion, postinfarction short-term exercise training increases the exercise tolerance, decreases the heart rate, systolic blood pressure, and double product response to exercise and improves the ischemic threshold.

Objective: Plasma cortisol in obese subjects does not differ from that in normoweight subjects. Extra-adrenal cortisol production by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) can result in local hypercortisolemia. The aim of the present study was to examine the role of visceral hypercortisolemia in the development of metabolic syndrome in severe obesity. Methods: Eight lean women during hysterectomy (controls) and 19 severely obese women during bariatric surgery were studied, 8 without metabolic syndrome (OM– group) and 11 with it (OM+ group). Biopsies of omental and subcutaneous fat were performed in the severely obese women during surgery, but only omental biopsies in the controls. Expression of 11β-HSD1, glucocorticoid receptor α (GRα) and glucocorticoid receptor β (GRβ) was evaluated using real-time PCR.Results: Omental 11β-HSD1 expression was different between groups (one-way ANOVA, p < 0.01). Post-hoc analysis revealed that mean omental 11β-HSD1 mRNA levels were higher in the OM– group compared to controls, whereas they were similar when comparing the OM+ group with lean controls. Expression of 11β-HSD1 in subcutaneous fat was not different between OM+ and OM– groups. GRα expression in omental fat did not differ among groups or between omental and subcutaneous fat in severely obese patients. An expression of GRβ was not detected.Conclusion: Contrary to our original hypothesis, omental 11β-HSD1 expression is not increased in the OM+ group.

The ratio of early diastolic transmitral velocity to early mitral annular diastolic velocity (E/Ea) can be used to group patients according to filling pressures. However this relationship has not been validated in the intermediate group (E/Ea = 8-15). The time difference between the onset of E and Ea also correlates with left ventricular (LV) filling pressures. The purpose of our study was to evaluate the correlation between the time interval difference of isovolumic relaxation (T[IVRT-IVRTa]) and N-terminal pro-brain natriuretic peptide (NTpro-BNP) in patients with an intermediate E/Ea ratio.Echocardiography was performed simultaneously with NTpro-BNP measurement in 60 consecutive patients who had an intermediate E/Ea and were in sinus rhythm. Ea and the isovolumic relaxation time (IVRTa) at the septal and lateral sites of the mitral annulus were measured using pulsed tissue Doppler and the average was utilised. Pulsed Doppler was used to measure E and IVRT. E/Ea and IVRT-IVRTa (T[IVRT-IVRTa]) were calculated.We demonstrated significant correlations between T[IVRT-IVRTa] and NTpro-BNP (r = -0.72, p0.001), maximal systolic velocity of the mitral annulus (Sa: r = -0.50, p0.001), pulmonary artery systolic pressure (r = 0.42, p = 0.002), IVRTa (r = -0.27, p = 0.03), LV ejection fraction (LVEF: r = -0.26, p = 0.04), IVRT (r = -0.24, p = 0.04). We were unable to demonstrate significant relationships between NTpro-BNP and E deceleration time, left atrial diameter/area/volume, Ea or E. By a multiple linear regression analysis, including T[IVRT-IVRTa], IVRT, IVRTa, E/Ea, LVEF, pulmonary artery systolic pressure and Sa as potential determinants, TIVRT-IVRTa (= -0.57, p0.001) was shown to be the best independent predictor of NTpro-BNP (r 2 = 0.68, p0.001).T[IVRT-IVRTa] correlates strongly with NTpro-BNP levels in patients with intermediate E/Ea, and could be used as a simple echocardiographic index, with reasonable accuracy.

We report a case of a 40-year-old primipara Caucasian woman with Turner syndrome (TS) and Hashimoto thyroiditis who had underwent a successful IVF-ET cycle with oocyte donation and single embryo transfer. All pregnancies in women with TS are considered as high risk, with cardiovascular complications being the most dangerous. Our case represents a typical case of fetal growth restriction with gradual slowing down of fetal growth after 28 weeks. At 37 + 3 gestational weeks, a healthy male newborn weighing 2240 g, with artery pH of 7.32 was delivered by cesarean section. The neonate was small for gestational age. Women with TS who become pregnant need close surveillance from a multidisciplinary team of cardiologists, obstetricians and endocrinologists. The primary goal is to prevent maternal complications and to improve perinatal outcome. In doing so, a thorough evaluation of fetal growth and uteroplacental and fetal circulation should by no means be omitted, after 26-28 weeks of gestation. The examinations should be at monthly or even shorter intervals to find early signs of growth restriction and act accordingly.

BACKGROUND Transesophageal echocardiography (TEE) is now an established adjunct to routine echocardiography, its diagnostic impact making it an invaluable first-line diagnostic procedure in many cardiac conditions. However, there is no unanimity in the way the transesophageal procedure is carried out, especially with regard to the need for antibiotic prophylaxis, sedation, and the monitoring of oxygen saturation. HYPOTHESIS This study was prospectively undertaken (1) to determine the presence and magnitude of oxygen desaturation and (2) the changes in heart rate and blood pressure following sedation for routine TEE in an unselected and consecutive group of patients to identify those at high risk. METHODS Arterial oxygen saturation, heart rate, and systolic, diastolic, and mean blood pressure were monitored in 106 consecutive patients undergoing routine transesophageal echocardiography. Ninety-four (89%) patients received intravenous sedation with midazolam. RESULTS Three min after midazolam administration there was a drop in oxygen saturation from 97 +/- 2.5 to 95 +/- 2.9 (p < 0.001), in systolic blood pressure from 139 +/- 19.5 to 124.8 +/- 22.2 mmHg (p < 0.001), in diastolic blood pressure from 86.6 +/- 19.9 to 77.5 +/- 17.7 mmHg (p < 0.001), and in mean blood pressure from 108.3 +/- 18 to 95.6 +/- 28.8 mmHg (p < 0.001). After introduction of the transesophageal probe and during the examination, there was a further drop in oxygen saturation with a maximum drop at the 15th min of the examination (93.7 +/- 3.7 vs. 97 +/- 2.5, p < 0.001). The maximum blood pressure drop occurred at the 12th min into recovery: systolic blood pressure dropped from 139 +/- 19.5 to 118 +/- 20.8 mmHg (p < 0.001), diastolic blood pressure from 86.6 +/- 16.9 to 75.8 +/- 17.9 mmHg (p < 0.005), and mean blood pressure from 108.3 +/- 18 to 92.5 +/- 19.4 mmHg (p < 0.01). Patients with congestive heart failure had a greater drop in oxygen saturation compared with patients who were not in heart failure (p < 0.01). Twelve patients did not receive any sedation; however, they all showed a drop in oxygen saturation from 97.8 +/- 2.3 to 94.6 +/- 3.4 (p < 0.001), with a maximum drop at the 15th min during the transesophageal examination. CONCLUSION In patients with no chronic obstructive airway disease who are not in congestive heart failure, routine oxygen saturation monitoring is not deemed necessary during transesophageal examination. The cause of hypoxemia during the procedure is not only related to sedation but also to esophageal intubation.

OBJECTIVE—To evaluate changes in left ventricular function and the impact of ventricular hypertrophy and pressure gradient early and late after aortic valve replacement in patients with isolated aortic stenosis. DESIGN—41 patients with isolated aortic stenosis and normal systolic function underwent cross sectional and Doppler echocardiography two months before and two weeks and four years after aortic valve replacement. RESULTS—Early after the operation, left ventricular mass index (mean (SD)) decreased from 187 (44) g/m2 to 179 (46) g/m2, because of a reduction in end diastolic diameter (p 13 mm) (p 30 mm Hg ) (p

We report the case of a patient who was admitted to the hospital with acute pulmonary embolism 2 weeks after a complicated pelvis fracture. Echocardiography revealed a large, long, and mobile thrombus in the right atrium. The patient was scheduled to undergo urgent surgical thrombectomy. Preoperative echocardiography did not detect any thrombi in the right heart and pulmonary artery. The obvious embolism of this large thrombus in the pulmonary circulation was silent as the patient remained asymptomatic and hemodynamically stable. We discuss the contribution of echocardiography to the appropriate therapeutic management of right atrial thrombi and particularly to the cancellation of urgent operative thrombectomy.

This study sought to determine the duration of new or worsening left ventricular regional wall motion abnormalities (RWMAs) after dobutamine stress echocardiography (DSE) and their relation to the extent of coronary artery disease (CAD).Despite extensive reports on DSE, little is known about the duration of new or worsening RWMAs during recovery. We hypothesized that the persistence of RWMAs during recovery may be associated with the extent of CAD and therefore ischemia.Sixty-five consecutive patients with positive results on DSE and angiographically documented CAD were studied. Each patient underwent 12-lead electrocardiography and two-dimensional echocardiography at rest, during dobutamine infusion and continuously during recovery to assess the recovery time of ischemic myocardial regions.All patients had at least one ischemic region during DSE. Complete resolution of RWMAs occurred within 25 min in patients with multivessel CAD, within 20 min in those with two-vessel disease and within 15 min in those with single-vessel disease (p0.001). The greater the wall motion score index at peak stress, the longer the duration of RWMAs into the recovery phase (p0.01). RWMAs persisted long after normalization of each patient's symptoms, electrocardiographic (ECG) changes, heart rate and rate-pressure product during recovery.We demonstrated that normalization of left ventricular RWMAs occurs after resolution of symptoms and ECG changes during recovery. The time to recovery is related to the extent of CAD and myocardial ischemia as well as to the presence or absence of collateral circulation. These findings may represent stunned myocardium after brief period of ischemia.

Polymerization reactor optimal design and control problems are inevitably multiobjective in nature. Copolymerization problems encompass an even larger set of objective functions than homopolymerization. This work describes in some detail a set of typical components of the vector of objective functionals for copolymerization reactor problems. A subset of these is selected for detailed examination employing multiobjective function optimization techniques. Noninferior, or Pareto, sets of optimal solutions have been determined for the dual objectives of narrowing both copolymer composition and molecular weight distributions in the styrene-acrylonitrile system. Noninferior solutions occur when the two objectives are in conflict and no objective can be improved without sacrifice of the other. We show for several sets of control variables that, in the S-AN system, one should seldom, if ever, control with respect to one objective functional exclusively. Compromise policies can be found which are close to utopian for both objectives. A better quantitative understanding of the trade-offs between objectives in copolymerization engineering has been achieved.