Massive congenital bidirectional coronary arteriovenous malformation presenting with signs and symptoms of congestive heart failure in an adult: a case report and review of the literature.

Congenital anomalies of the coronary arteries are relatively rare. Mostly asymptomatic, however, some can cause problems, as heart failure, myocardial ischemia, and ventricular arrhythmia, and are associated with risk of complications, such as endocarditis and coronary rupture or sudden death. A case of a 69-year-old man with complaints of tiredness, dyspnea, and palpitation due to coronary artery fistula is presented with a review of the literature.

Left main stem disease in a patient with Takayasu's arteritis.

Takayasu's arteritis is a chronic vasculitis of unknown aetiology involving the aorta and its main branches, the pulmonary and coronary tree. Women are affected more often than men (80 to 90% of the cases) with an age onset between 10 and 40 years. This case report demonstrates the limitations of exercise testing and stress echocardiography in diagnosing the extent of coronary artery disease in patients with inflammatory disease in the left main stem coronary artery. (Neth Heart J 2007;15:260-2.).

Staff radiation doses to the lower extremities in interventional radiology.

The purpose of this study was to investigate the radiation doses to the lower extremities in interventional radiology suites and evaluate the benefit of installation of protective lead shielding. After an alarmingly increased dose to the lower extremity in a preliminary study, nine interventional radiologists wore thermoluminescent dosimeters (TLDs) just above the ankle, over a 4-week period. Two different interventional suites were used with Siemens undercouch fluoroscopy systems. A range of procedures was carried out including angiography, embolization, venous access, drainages, and biopsies. A second identical 4-week study was then performed after the installation of a 0.25-mm lead curtain on the working side of each interventional table. Equivalent doses for all nine radiologists were calculated. One radiologist exceeded the monthly dose limit for a Category B worker (12.5 mSv) for both lower extremities before lead shield placement but not afterward. The averages of both lower extremities showed a statistically significant dose reduction of 64% (p < 0.004) after shield placement. The left lower extremity received a higher dose than the right, 6.49 vs. 4.57 mSv, an increase by a factor of 1.42. Interventional radiology is here to stay but the benefits of interventional radiology should never distract us from the important issue of radiation protection. All possible measures should be taken to optimize working conditions for staff. This study showed a significant lower limb extremity dose reduction with the use of a protective lead curtain. This curtain should be used routinely on all C-arm interventional radiologic equipment.

Incidence and ossification of sesamoid bones in the hands and feet: a radiographic study in an Arab population.

The incidence and ossification of sesamoid bones in the hands and feet were studied in 922 radiographs (400 hands and 522 feet) in an Arab population from Bahrain, 5-83 years of age and consisting of 549 adults (393 men and 156 women) and 373 children (286 boys and 97 girls). All radiographs of the hand and foot in the adult population showed two sesamoid bones in the thumb metacarpophalangeal (MCP) joint and in the hallucal metatarsophalangeal (MTP) joint, respectively. Only 2.3% and 1.5% of hands showed sesamoids at the MCP joints of the middle and ring fingers respectively compared to a reported incidence of 7.1% for each digit in Caucasians. The incidence of sesamoids in the MTP joints of third and fourth toes (0.6% each) and inferior to the hallucal interphalangeal joint (3.1%) is probably the lowest reported so far in the literature. In the hands, ossification commenced first in the thumb sesamoids, at the age of 10 years in females and 11 years in males and was completed by the age of 13 and 14 years, respectively. In the feet, ossification began first in the hallucal sesamoids at the age of 8 years in females and 9 years in males and was completed by the age of 10 years in both sexes. The incidence and ossification of sesamoids in the hands and feet in the Arab population from Bahrain seem to differ considerably from reports in other populations. The clinical significance of our findings is discussed.

The hamate facet of the lunate: a radiographic study in an Arab population from Bahrain.

Based on the presence of a facet for the hamate two types of lunate bone have been described in the wrist; type I is without a facet for the hamate while type II bears a facet on the medial surface for articulation with the proximal pole of the hamate. Compared to type I lunates, type II lunates have been shown to have different kinematics, are more prone to clinically relevant degenerative changes in the hamato-lunate joint and may cause ulnar-sided wrist pain. The incidence of type II lunates seems to vary in different populations. Postero-anterior (PA) view of plain radiographs of the hand was studied in Arab subjects from Bahrain (n=381; 307 males and 74 females) to determine the incidence of type I and type II lunates. The mean age of the subjects was 31.1 years, the range being 18-80 years. In the population studied, only 148 (38.8%) of the 381 wrists showed type II lunate; 121 (31.7%) were found in males and 27 (7.1%) in females. There was no significant difference in the mean age of subjects with type I or type II lunates (P=0.16). There was no correlation between side and gender with the presence or absence of a hamate facet on the lunate. The incidence of type II lunate was much lower than reports in the literature of populations from the Western world, which could be attributed to a genetic variation in the Arab population in Bahrain. These data indicate that osteoarthritis of the hamate or lunate is less likely to be a cause of ulnar-sided wrist pain in Bahraini Arabs.

Role of echocardiography in the diagnosis and management of infective endocarditis.

Infective endocarditis is one of the most common causes of serious infection and carries a high risk of morbidity and mortality. It represents the fourth leading cause of life-threatening infections after urosepsis, pneumonia, and intra-abdominal sepsis. There is still a continuous rise in the incidence of infective endocarditis, with a rate of about 20,000 new cases in the United States alone. This rise in incidence of infective endocarditis is mainly caused by increasing numbers of intravenous drug abusers, patients with artificial valves and elderly patients. In this paper, we will briefly review the crucial role of echocardiography in the diagnosis and management of infective endocarditis.

Coexistence of a bradycardia- and tachycardia-dependent bundle branch block.

Aberrant ventricular conduction is a rare phenomenon as compared with the more frequently occurring antrioventricular conduction disturbances. It leads to widening of the QRS complex, which is either due to a complete or functional block in one of the bundle branches or a block within the intramyocardial conduction system itself. Mechanisms that are potentially involved in the genesis of aberrant ventricular conduction are sudden shortening of cycle length (tachycardia-dependent phase III), antegrade block with retrograde concealed conduction, or bradycardia-dependent block (enhanced phase IV). In this paper, we present a patient with aberrant ventricular conduction with the occurrence of a tachycardia-dependent, as well as a bradycardia-dependent bundle branch block, which is an even rarer phenomenon.

Arrhythmogenic right ventricular dysplasia as a possible cause of sudden cardiac death: a case report and clinical review.

Sudden cardiac death can be described as an unexplained natural death due to a cardiac cause. It occurs within a short period, one hour or less, after onset of symptoms in a person without any prior medical history. Among the many causes of unexplained sudden cardiac death, we would like to specifically discuss arrhythmogenic right ventricular dysplasia as a rare cause in otherwise healthy and usually young individuals.

Imaging of a non-coronary sinus of Valsalva aneurysm with transthoracic echocardiography and multi-slice computed tomography.

A 46-year-old female with a giant aneurysm of the non-coronary sinus of Valsalva, associated with moderate aortic valve regurgitation, is described. The aneurysm was detected by echocardiography in a patient who was complaining of paroxysmal palpitations. The patient was accepted for aneurysmectomy. In this case report the possible aetiologies and clinical aspects of the aneurysm are reviewed. Treatment and the role of multi-sliced computed tomography (MSCT) in heart disease are discussed.

A usual presentation of an unusual diagnosis.

Chest pain is one of the most common acute medical emergencies and a significant proportion of cases will manifest in one of the acute coronary syndromes. We report a case in which an intermittent non-specific chest pain led to the detection of primary mediastinal large B-cell lymphoma.

Conformational analysis of a flexible oligosaccharide using residual dipolar couplings.

We present a new approach to the analysis of the conformational and the motional properties of an oligosaccharide, methyl 3,6-di-O-(alpha-D-mannopyranosyl)-alpha-D-mannopyranoside. The approach relies on an order matrix analysis of residual dipolar couplings in the solution state. By combining a number of different types of couplings, (1)D(CH), (2)D(CH), and D(HH), an order matrix is solved for each ring of the trimannoside. The resulting order parameters indicate the internal motion at the alpha (1,3) linkage to be limited, while significant motion is suggested at the alpha (1,6) linkage. Two structures for the trimannoside were determined by aligning the order tensor principal axes obtained from two different orienting media, bicelles and phage. The very similar conformations at the alpha (1,3) linkage of these two structures confirm that the internal motion at the alpha (1,3) linkage is small and the conformation is a good representation of a single preferred structure. The different conformations at the alpha (1,6) linkage suggest that the motional amplitudes are large and the conformations must be viewed as virtual conformers. Compared with traditional NMR methods, data acquisition is easy and data analysis is straightforward.

Field- and phage-induced dipolar couplings in a homodimeric DNA quadruplex: relative orientation of G.(C-A) triad and G-tetrad motifs and direct determination of C2 symmetry axis orientation.

We present a new NMR procedure for determining the three-dimensional fold of C2-symmetric nucleic acid homodimers that relies on long-range orientational constraints derived from the measurement of two independent sets of residual dipolar couplings under two alignment conditions. The application is demonstrated on an (15)N/(13)C-enriched deoxyoligonucleotide sequence, d(G-G-G-T-T-C-A-G-G), shown previously to dimerize into a quadruplex in solution and form a pair of G.(C-A) triads and G-G-G-G tetrads (G-tetrad) motifs. One-bond (1)H-(15)N ((1)D(NH)) and (1)H-(13)C ((1)D(CH)) residual dipolar couplings have been measured between nuclei in the bases of these motifs using bacteriophage as an ordering medium, and under direct magnetic field alignment (800 MHz). By combining the two dipolar data sets in an order matrix analysis, the orientation of the G.(C-A) triad relative to the G-tetrad within a contiguous monomeric unit can directly be determined, even in the presence of interstrand/intrastrand NOE ambiguity. We further demonstrate that the orientation of the C2-axis of molecular symmetry in the homodimer relative to the G.(C-A) triad and G-tetrad motifs can unambiguously be determined using the two sets of independent dipolar coupling measurements. The three-dimensional fold of the homodimer determined using this procedure is very regular and in excellent agreement with a previously determined high-resolution NOE-based NMR structure, where interstrand/intrastrand NOEs were treated as ambiguous and where noncrystallographic symmetry constraints were implicitly imposed during the structure calculation.

Structural and dynamic analysis of residual dipolar coupling data for proteins.

The measurement of residual dipolar couplings in weakly aligned proteins can potentially provide unique information on their structure and dynamics in the solution state. The challenge is to extract the information of interest from the measurements, which normally reflect a convolution of the structural and dynamic properties. We discuss here a formalism which allows a first order separation of their effects, and thus, a simultaneous extraction of structural and motional parameters from residual dipolar coupling data. We introduce some terminology, namely a generalized degree of order, which is necessary for a meaningful discussion of the effects of motion on residual dipolar coupling measurements. We also illustrate this new methodology using an extensive set of residual dipolar coupling measurements made on (15)N,(13)C-labeled human ubiquitin solvated in a dilute bicelle solution. Our results support a solution structure of ubiquitin which on average agrees well with the X-ray structure (Vijay-Kumar, et al., J. Mol. Biol. 1987, 194, 531--544) for the protein core. However, the data are also consistent with a dynamic model of ubiquitin, exhibiting variable amplitudes, and anisotropy, of internal motions. This work suggests the possibility of primary use of residual dipolar couplings in characterizing both structure and anisotropic internal motions of proteins in the solution state.