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Background: Cardiac manifestations of Whipple disease are rarely diagnosed before death., Objective: To describe four patients with endocarditis caused by Tropheryma whippelii who did not have overt gastrointestinal disease., Design: Case series., Setting: Five hospitals in eastern Switzerland., Patients: Three men and one woman undergoing replacement of insufficient heart valves., Measurements: Histologic characteristics of heart valves and intestinal biopsy; broad-range and specific polymerase chain reaction for T. whippelii., Results: Tropheryma whippelii was found in the heart valves (three aortic valves and one mitral valve) of four patients with culture-negative endocarditis necessitating valve replacement. All patients had arthralgia for different lengths of time. Only one patient had mild gastrointestinal symptoms. Histologic characteristics of intestinal mucosa were normal in all patients, and polymerase chain reaction on intestinal biopsy was positive for T. whippelii in only one patient, who did not have diarrhea. In all patients, arthralgia resolved promptly after institution of antibiotic therapy. Disease did not recur in any patient after prolonged antibiotic therapy with cotrimoxazole., Conclusion: In patients with culture-negative endocarditis, the absence of clinical, microscopic, or microbiological evidence of gastrointestinal disease did not rule out T. whippelii.

Unlabelled: The frequency of adverse effects caused by doctors may serve as a quality control. We therefore assessed the number of adverse effects leading to a hospital admission and occurring during a six-month period in the medical department of a district hospital. We compared these figures with the number of admissions caused by substance-abuse by the patient himself., Results: At admission to hospital 35 patients (6.4%) suffered from adverse effects. In 89% of these, the adverse effect was the leading factor to admit the patient; in the remaining 4 patients (11%) the adverse effect was detected by routine-screening upon admission. Further 8.6% developed adverse effects in the hospital which in 12.5% had consequences upon course and duration of the hospitalization. Self-afflicted hospital-admissions (substance-abuse, suicide-attempts) were found in 13%. Iatrogenic adverse effects brought 3.5% of the patients to the hospital., Conclusions: Adverse effects caused by diagnostic and therapeutic activities of doctors considerably contribute to hospital-admissions and course of hospital-stay, but even more often the patient himself is responsible by his self-damaging behavior.

To find out how well informed they were about their disease and operation, 104 patients who had undergone aortocoronary bypass surgery (group A) or heart valve replacement (group B) were asked to complete a questionnaire on discharge from the operating hospital and, after patient briefing during in-hospital rehabilitation, again 3 months after the operation. The level of anxiety and presence of depression were also assessed. We found the following percentages of wrongly or inadequately answered questions (the figures in brackets are from the second questionnaire 3 months after the operation): all questions 40 (27), anticoagulation 26 (15), prophylaxis of endocarditis 54 (29), risk factors 21 (21), nutrition 56 (38), exercise 47 (32), anatomy/physiology 35 (21), postoperative course 40 (24). The learning effect was significant (p less than 0.005) for all but the risk factor questions. There were no significant differences between men and women or between group A and group B. With a proportion of 14% (13%) anxiety was a common problem which had subsided by the end of rehabilitation. With percentiles of 3% (5%), depression was rare.

Two case reports and a review of the literature on ECG changes and myocardial damage (subendocardial hemorrhages and focal myocytolysis) in patients with acute brain lesions are presented. The implications and problems associated with these changes are discussed, particularly in relation to the evaluation of potential cardiac transplant donors.