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At least 1,675 records · Page 93Linked to original sources
PubMed1996

[Ultra-high dosage streptokinase lysis in dysfunction of a St. Jude aortic prosthesis].

HISTORY AND CLINICAL FINDINGS: A 64-year-old man was hospitalised because of progressively worsening dyspnoea over the preceding few months. Three years previously he had undergone aortic valve replacement (St. Jude Medical bileaflet valve) for severe aortic stenosis and some regurgitation. He was much improved postoperatively and one year after the operation echocardiography demonstrated a well functioning prosthetic valve and a transvalvar pressure gradient (by Doppler echocardiography) of 28 mm Hg. On admission the patient reported to have stopped phenprocoumon 9 months before admission. The patient was in cardiac failure, grade III (NYHA classification). On auscultation there was a 4/6 crescendo-decrescendo systolic murmur and a 2/6 early diastolic decrescendo murmur maximal over the second right ICS. INVESTIGATIONS: Echocardiography confirmed the suspected diagnosis of dysfunction of the prosthetic valve, one leaflet being immobile, with severe outflow obstruction (peak transvalvar pressure gradient 101 mm Hg) combined with severe regurgitation. At fluoroscopy one leaflet moved normally, the other one being fixed between opening and closing positions. TREATMENT AND COURSE: As thrombosis was the most likely cause of the prosthetic valve dysfunction, thrombolysis treatment was started. After administration of 9 mill. IU streptokinase both leaflets showed normal movement. The peak transvalvar gradient (by echocardiography) was now 40 mm Hg and there was only slight regurgitation. No complications were noted. After oral anticoagulation for 6 months the prosthetic valve was functioning normally with unchanged movement pattern of both leaflets. CONCLUSION: Thrombolysis may be successful in thrombotic dysfunction of a prosthetic valve. If there are no contraindications, this form of treatment should be tried before reoperation is undertaken.

Aortic Valve↗
PubMed1996

[Splenic infarction caused by paradoxical emboli in severe pulmonary hypertension].

HISTORY AND CLINICAL FINDINGS: A 55-year-old woman developed increasing shortness of breath and breath-independent pain in the left lower chest. 20 years previously she had had an episode of pulmonary embolism and 10 years previously a central venous thrombosis in the left eye. No cause of the increased thrombogenesis had been found. On admission she had resting dyspnoea but a stable circulation. On auscultation the breath sounds were diminished over the left base and there was a diastolic murmur over the pulmonary area with an accentuated second sound. There was also marked tenderness below the left costal margin. Recurrent pulmonary embolism or left-sided pleuropneumonia was suspected. INVESTIGATION: Arterial blood gases (without additional oxygen) showed severe hypoxaemia (pO2 42.3 mm Hg, pCO2 27.8 mm Hg, pH 7.455, oxygen saturation 80.5%). Transthoracic and transoesophageal echocardiography showed normal left ventricular dimensions, right atrial and ventricular dilatation, and an atrial septal aneurysm with a right to left interatrial shunt. Right heart catheterisation demonstrated severe pulmonary hypertension. Sonography, computed tomography and scintigraphy revealed multiple splenic infarcts. TREATMENT AND COURSE: Heparinisation was instituted (partial thromboplastin time 70-90 s) and overlapping oral anticoagulation to a Quick value of 20%. Subsequently the calcium antagonist felodipine (15 mg daily) was given. The mean pulmonary artery pressure was 61 mm Hg before and 57 mm Hg after treatment. CONCLUSION: Splenic infarction resulting from paradoxical embolisation is rare, but should be routinely considered in the presence of thromboembolic phenomena.

Angiography↗
PubMed1996

[Is a clinical positional control for nasogastric tubes good enough? A prospective study of 43 patients].

OBJECTIVE: Nasoenteric tubes are usually introduced blindly by nursing staff, i.e. without visual or radiological control. A prospective study was undertaken to determine how often such blind procedure results in potentially dangerous tube placement and how often such faulty positioning remains undetected in a standardised clinical check. PATIENTS AND METHODS: 43 patients (23 men, 20 women; age 24-90 years) requiring the introduction by nursing staff of a nasoenteric tube were studied, 12 in an intensive care unit (seven intubated) and 31 in an ordinary ward. At most 24 hours after the customary check of the tube's position by the nursing staff (air injection with epigastric auscultation), specially experienced medical and nursing personnel determined and recorded the tube's placement in a standardised manner. Subsequent radiological examination documented the position. RESULTS: All 43 tubes lay in the gastrointestinal tract. Only one tube was in a potentially dangerous position in the lower end of the oesophagus, as had already been diagnosed by the examiners. Of four other tubes which were not optimally placed (three in the region of the cardia, one in the duodenum) three were found to be "not correctly placed" by the clinical check, and one was detected only radiologically. CONCLUSIONS: Clinical control of a nasoenteric tube's position suffices in most instances. Checking the position further by an experienced person adds to safety. The study's findings suggest that radiological control can be safely limited to cases in which there was a problem in positioning the tube or the clinical control was unclear.

Adult↗
PubMed1997

[Septic myocardial aneurysm in mitral valve endocarditis. Clinical and pathological-anatomical findings].

HISTORY AND CLINICAL FINDINGS: A 68-year-old woman was hospitalized because of fever and tiredness for 3 months. Her general condition was clearly impaired. She had a mild fever of 38.5 degrees C and on auscultation a 3/6 systolic murmur, maximal parasternally in the 3rd intercostal space, transmitted to the apex. There were distant râles over both lungs, the neck veins were distended and there was ankle oedema. INVESTIGATIONS: C-reactive protein was raised to 17.3 mg/dl (normal up to 0.9 mg/dl), WBC count 19,300/microliter. beta-haemolysing streptococcus (S. agalactiae) was grown in the blood culture. The ECG showed sinus tachycardia (rate of 98/min) and transthoracic echocardiography demonstrated a small pericardial, enlarged ventricles, marked mitral regurgitation and a large vegetation on the posterior mitral leaflet, as well as a 3 x 4 cm mass in the posterior wall of the ventricle, originating from the posterior mitral valve ring and communicating with the vegetation on the mitral valve. The posterior mitral leaflet was perforated. TREATMENT AND COURSE: As endocarditis of the mitral valve with a complicated course was suspected-abscess of the posterior mitral valve ring and septic myocardial aneurysm with associated pericarditis and haemodynamically insignificant effusion-she was transferred to the intensive care unit where she died suddenly of circulatory arrest only 30 min after transfer. Autopsy confirmed the echocardiographic findings. CONCLUSION: Paravalvular abscess in the course of mitral valve endocarditis is rare, but should be looked for at transthoracic echocardiography so that any necessary surgical intervention can be undertaken early.

Aged↗
PubMed1997

[Refractory hydrothorax in primary biliary cirrhosis: successful treatment with transjugular intrahepatic portosystemic stent shunt].

HISTORY AND CLINICAL FINDINGS: A 55-year-old woman with known primary biliary cirrhosis (PBC) was hospitalized because of increasing dyspnoea. A year before she had for the first time experienced a right-sided pleural effusion which had to be drained every 4 weeks. Physical examination revealed dullness on percussion and greatly decreased breath sounds on auscultation over the entire right thorax. In addition there were signs of moderate ascites and leg oedema. INVESTIGATIONS: Chest radiograph showed a homogeneous shadowing of the right thorax without mediastinal shift. Diagnostic thoracocentesis produced a serous effusion, a transudate on chemical analysis, comparable to the composition of the ascitic fluid. Bacteriological and cytological tests on both fluids were unremarkable. TREATMENT AND COURSE: The right pleural effusion was presumed to be due to a hydrothorax from the ascites caused by portal hypertension associated with the PBC. Despite continuous diuretic treatment and thoracocentesis with albumin substitution every 3 days there was no improvement and implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) was performed. This effectively lowered portal pressure and markedly improved the patient's condition so that further thoracocentesis were no longer necessary. 3 weeks after TIPSS implantation she was discharged in good condition. Radiography 3 weeks later demonstrated continued reduction in the hydrothorax. CONCLUSION: Hydrothorax is a rare complication of liver cirrhosis. TIPSS implantation can provide lasting resolution and corresponding clinical improvement of a hydrothorax, especially in those conditions which are refractory to diuretic treatment and thoracocentesis.

Diuretics↗
PubMed1995

[Chronic granulomatosis: a rare differential diagnosis in liver granulomas in adulthood].

A now 43-year-old man was known since childhood to have mesenteric and subcutaneous lymphadenopathy. Histological examination of liver biopsies and excision of some lymph nodes when an adult showed epithelioid granulomas, in places with Langhans giant cells. Diagnostic splenectomy revealed no pathological findings. His present admission to hospital was for an infection with high fever. On auscultation moist rales were audible over the apex of the left lung. The chest radiography showed pneumonic infiltration. Blood culture grew Pseudomonas aeruginosa. Ultrasound demonstrated hypoechogenic homogeneous and smoothly circumscribed round foci in the liver hilus and around the coeliac trunk. The upper lobe pneumonia healed under antibiotic treatment. As chronic granulomatosis was suspected, the nitroblue tetrazolium and superoxide production tests were performed. They demonstrated that the capacity of the granulocytes to form oxygen radicals was markedly diminished. Chronic granulomatosis is an inherited disorder of granulocyte function linked to the X-chromosome. It must be included in the differential diagnosis of any unclear granulomatous disease even in adults.

Adult↗
PubMed1995

[Thrombosis of a prosthetic mitral valve in the anticardiolipin syndrome].

A 40-year-old woman in whom the mitral valve had to be replaced with a prosthetic one (St. Jude's) had to be reoperated 8 months later because of endocarditis on the second prosthetic valve (Carbo-Medics). Four months later her general condition deteriorated progressively with cough and dyspnoea, requiring hospitalization. Auscultation revealed moist rales over both lung bases; heart sounds were distant but otherwise normal. The "international normalized ratio" was 2.5, while erythrocyte sedimentation rate, white cell count and C-reactive protein were normal. Transthoracic echocardiography demonstrated a hardly moving mitral valve prosthesis with an opening area of 0.8 cm. Subsequently this decreased further and measurement of the anticardiolipin antibody titre revealed an IgG fraction of 37.9 U/ml (normal up to 12 U/ml). Within 48 hours thrombolysis with streptokinase had increased the valve's opening area to 1.8 cm. The patient made an uneventful recovery under strict anticoagulation. This case illustrates that the anticardiolipin syndrome can be a cause of an otherwise unclear genesis.

Adult↗
PubMed1995

[Ectopic thyroid tissue in the heart--two case reports].

A 61-year-old previously healthy woman had been suffering from a dry cough for several weeks. On auscultation she had a 3/6 holosystolic murmur. The electrocardiogram (ECG) showed incomplete right bundle branch block (IRBBB) and abnormal repolarisation. Conventional and oesophageal echocardiography revealed a right ventricular tumour and significant coronary heart disease. At operation a tumour, arising from the interventricular septum and histologically consisting of thyroid tissue, was resected. In addition, the left mammary artery was anastomosed to the anterior interventricular branch of the left coronary artery. A 34-year-old woman developed increasing exertion-independent dyspnoea. For years she had had occasional attacks of palpitations and restlessness, once even a syncope. The ECG showed IRBBB, echocardiography demonstrated a tumour attached to the right side of the interventricular septum. The tumour was removed and found histologically to consist of colloid-containing thyroid follicles. Both tumours were benign. 45 and 36 months, respectively, later both patients are free of symptoms.

Adult↗
PubMed1995

[The perforation of a right-coronary sinus of Valsalva aneurysm into the right atrium].

HISTORY AND CLINICAL FINDINGS: A 58-year-old man [correction of woman] without previous cardiac symptoms developed exertional dyspnoea and peripheral oedema which markedly increased within a two-week period. Auscultation revealed a 4/6-5/6 holosystolic and diastolic machinery murmur. EXAMINATIONS: Transthoracic and multiplane transoesophageal echocardiography established the diagnosis of a 3 cm aneurysm of the right coronary sinus of Valsalva with clearly demarcated rupture into the right atrium, with a large left to right shunt shown on colour-Doppler echocardiography. These findings were confirmed on cardiac catheterisation. There was no sign of coronary heart disease. TREATMENT AND COURSE: At open-heart surgery the aneurysm was resected, the defect closed with an autologous pericardial patch and the tricuspid valve reconstructed. On follow-up examination the result remained excellent and the patient was free of symptoms. CONCLUSION: In ruptured aneurysm of the coronary sinus of Valsalva, multiplane transoesophageal echocardiography provides exact diagnosis and optimal planning of the operative procedure.

Aortic Rupture↗
PubMed1994

[Isolation of Chlamydia pneumoniae in atypical pneumonia].

A 33-year-old man, who two months previously had been treated for bronchopneumonia with cefuroxime, fell ill again with cough, dyspnoea and fever up to 39.8 degrees C. Auscultation and lung function tests indicated respiratory tract obstruction. The chest radiograph revealed an infiltrate of the left lower lobe and bronchoscopy showed hypertrophic bronchitis. Empirical antibiotic treatment with clarithromycin (initially 500 mg twice daily, continued on half this dose) lead to rapid improvement of clinical symptoms and the patient could be discharged after 9 days. A follow-up examination 3 months later showed no abnormality. A cell culture procedure using bronchoalveolar lavage fluid obtained during bronchoscopy permitted the continuous demonstration of Chlamydia pneumoniae inclusions in HEp-2 host cells by immunofluorescence microscopy. In parallel, Chlamydia pneumoniae DNA was specifically demonstrated in the lavage fluid by use of the polymerase chain reaction. This is the first reported isolation of a replicative Chlamydia pneumoniae strain in Germany.

Adult↗
PubMed1994

[Iodine-induced hyperthyroidism in metastatic thyroid carcinoma].

A 75-year-old man with nodular goitre (for the preceding 2 years treated with 75 micrograms/dl L-thyroxine) complained of pain over the left hip: on auscultation an arterial flow murmur was audible over the hip. The radiograph demonstrated extensive osteolysis in the flat part of the ilium. Search for the primary tumour, including two pelvic angiographs, was unsuccessful. Examination of a biopsy from the right ilium revealed a metastasis from a highly differentiated follicular thyroid carcinoma, which could not be demonstrated scintigraphically because of a reduced 99mTc-pertechnetate and 123I-iodine uptake, the result of the L-thyroxine administration. A thyrotoxic crisis occurred 2 days after the second angiography (free thyroxine 3.17 ng/dl, triiodothyronine 219 ng/dl, thyroglobulin > 250 ng/ml). Treatment with thiamazole (40 mg/d) and perchlorate (1 g/d) reduced the concentration of peripheral thyroid hormone, but the patient's general condition improved only slowly. As a result, radioiodine treatment could not be started until 9 months later. He died a further 9 months later from septicaemia originating from the metastasis.

Adenocarcinoma, Follicular↗
PubMed1993

[A Q fever epidemic in Berlin. The epidemiological and clinical aspects].

An epidemic of Q fever in Berlin affected at least 80 patients (45 females, 35 males; age range 1-75 years). Sheep were identified as the focus of infection: they had been brought to a veterinary clinic because of nonspecific symptoms. The peak incidence of the infection was in April and May, 1992. Most of the patients were staff or students at the veterinary clinic. This is the most northern and, at the same time largest, Q fever epidemic recorded in Germany over the last 28 years. The complement fixation reaction (CFR) was not helpful diagnostically in the acute stage of the disease as it remained negative in the first 14 days (CFR < or = 1:5). Most of the patients had sudden fever to over 40 degrees C, severe headache and dry cough. Pulmonary infiltrates were seen in the chest radiograph of 8 of the 10 patients presented in this contribution. Auscultation was largely negative. Two patients had signs of hepatic involvement (GPT as high as 71 U/l). The drug of choice was doxycycline at a dosage of 200 mg twice daily for 14 days.

Adolescent↗
PubMed1992

[Embolizing aortic valve endocarditis in the differential diagnosis of thrombotic thrombocytopenic purpura].

A 50-year-old man complained of lumbar pains, lack of energy, dysarthria and ataxic gait. Investigation revealed progressive anaemia (haemoglobin initially 10.5 g/dl, later 6.8 g/dl) and thrombocytopenia (initially 67,000/microliters, later 25,000/microliters). In addition he had unexplained pyrexia of up to 39.8 degrees C. Lactate dehydrogenase was 780 U/l and fragmented red cells were noted in the blood film. Because of suspicion of thrombotic thrombocytopenic purpura, treatment with fresh plasma by infusion was immediately initiated. On the third day of treatment he developed left ventricular failure; auscultation revealed a blowing early diastolic murmur over Erb's point together with a spindle-shaped early diastolic murmur over the right second intercostal space. Computed tomography of the skull showed recent haemorrhage into the left half of the cerebellum and an older right posterior infarct. The abdominal ultrasound scan suggested a haemorrhagic spleen infarct. In view of these findings the diagnosis was revised to embolizing aortic endocarditis with aortic reflux (confirmed by colour Doppler echo-cardiography). Aortic valve replacement was performed immediately, and the patient was treated with gentamycin 80 mg/d and teicoplanin 400 mg/d for four weeks. Postoperatively he was given 12 units of platelet concentrate and the platelet count remained stable thereafter (greater than 100,000/microliters). Splenectomy became necessary because the splenic haematoma increased in size during oral anticoagulant therapy. After a 6 week hospital stay the patient was discharged in good condition.

Anti-Bacterial Agents↗
PubMed1992

[Morgagni's hernia: diagnosis and therapy].

A 35-year-old man reported persistent exertional dyspnoea and pressure sensation over the left chest for the last six weeks. On auscultation there were diminished breath sounds over the right base. Chest X-ray demonstrated a 10 cm large ventral paracardiac shadow on the right. Computed tomography suggested a hernia of the foramen of Morgagni; persisting symptoms indicated a laparotomy. This revealed an opening of about 1.5 cm in the right substernocostal triangle through which the entire greater omentum had herniated into the thorax. The omentum was repositioned and the hernial defect closed by direct suture. The postoperative course was without complication and the patient was discharged after seven days.

Adult↗
PubMed1997

Common feeding problems in the intensive care nursery: maturation, organization, evaluation, and management strategies.

This paper reviews current literature on feeding and swallowing of the premature and high-risk infant. If addresses issues of maturation and organization that affect feeding abilities. Evaluation issues including instrumental evaluations (e.g., cervical auscultation, modified barium swallow studies) are discussed. Finally, common problems seen in this population are described along with the wide range of management strategies to consider. Whenever intervening with this fragile population a team approach must be used; the individual needs and behavioral cues of the infant must be read, respected, and responded to, while ensuring that families play an integral part of the process.

Deglutition Disorders↗
PubMed1996

Specialized studies in pediatric dysphagia.

The evaluation and management of the pediatric patient with a feeding and swallowing disorder may require the use of specialized studies to evaluate specific aspects of swallowing function; to judge the consequences of the swallowing dysfunction; and to assess factors that may be contributing to swallowing dysfunction. Instrumental assessment of swallowing function may include upper gastrointestinal studies, videofluoroscopy or videofluoroscopic swallow studies, ultrasonography, radionuclide imaging, fiberoptic endoscopy of swallowing, and cervical auscultation. Procedures that assess the consequences and/or identify factors contributing to swallowing dysfunction may include pulse oximetry, chest x-rays, laryngoscopy and/or bronchoscopy, and pulmonary function tests. The use of such specialized procedures to evaluate children with dysphagia is the focus of this article.

Deglutition Disorders↗
PubMed1986

[Biatrial myxomas--a diagnostic challenge].

Like isolated cardiac myxoma, biatrial myxoma may manifest itself only by extracardiac symptoms over a prolonged period. A 24-year-old patient presented over seven years a history of repeated arthalgia with concomitant anaemia, elevated blood sedimentation rate, positive antistreptolysin test and electrophoretic signs of inflammation. A discrete systolic sound on auscultation gave rise to an echocardiographic examination which revealed a biatrial myxoma.

Adult↗
PubMed1986

[Bleaching agent poisoning with sodium chlorite. The toxicology and clinical course].

A woman gardener of 49 years of age suffered an inhalational intoxication from chlorine dioxide while bleaching dried flowers. Preparation of the bleaching solutions was associated with a sharp pungent smell, coughing, pharyngeal irritation and headache. Seven hours later increasing cough and dyspnoea led to hospitalisation. Clinical findings were tachypnoea, tachycardia, and rales of auscultation; clinical chemistry revealed marked leucocytosis. Chest X-ray did not yield any abnormal findings. Initially the vital capacity and forced expiratory volume in 1 s markedly reduced and the resistance correspondingly enhanced. Blood gas analysis showed hypoxaemia despite alveolar hyperventilation. Administration of corticosteroids resulted in significant alleviation of complaints and in improved lung function with stabilisation in a highly normal range, as confirmed by follow-up examination two years later. The chlorine dioxide intoxication had been due to pH level reduction resulting from an incorrect proportioning and handling of the individual bleaching agent components when preparing the solution.

Chlorides↗