Phytophthora cinnamomi as a Contributor to White Oak Decline in Mid-Atlantic United States Forests.

To evaluate Phytophthora cinnamomi as a cause of white oak (Quercus alba) decline in mid-Atlantic forests, sampling was conducted at 102 sites from 2011 to 2012. Soil and roots from healthy and declining white oak trees were collected. Phytophthora spp. were isolated using baiting and CFU of P. cinnamomi quantified using wet-sieving. Fine roots were scanned and measured. Phytophthora spp. were isolated from 43% of the sites. P. cinnamomi was common; six other species were isolated infrequently. Little difference in lesion size existed on white oak seedlings inoculated with 32 isolates of P. cinnamomi; only 13 isolates caused significant mortality. Soils from white oak versus nine other hosts did not have significantly different CFU. P. cinnamomi was restricted to United States Department of Agriculture hardiness zones six and seven and never found in zone five. The presence of Phytophthora spp. in soil can be associated with white oak fine root health. When Phytophthora spp. were present, white oak trees in zones five and six had less fine roots. In mid-Atlantic oak forests, however, environmental conditions appear to play a key role in determining the impact of P. cinnamomi on the root system. P. cinnamomi alone does not appear to be a causal factor of white oak decline.

Pulmonary arterial hypertension in patients with prior atrial switch procedure for d-transposition of great arteries (dTGA).

UNLABELLED: Pulmonary arterial hypertension (PAH) is an uncommon complication of atrial switch repair (Mustard or Senning) for d-transposition of the great arteries (dTGA), often difficult to diagnose by trans-thoracic echocardiography. This patient population is unique in that heart failure and elevated filling pressures are common after atrial switch repairs. Most studies evaluating the use of PAH therapies have excluded this group of patients. METHODS: Our echocardiography database was reviewed for patients with a diagnosis of dTGA status post-atrial switch operation treated with pulmonary vasodilator therapy (monotherapy or combination). RESULTS: Six patients (2 male, 4 female) were identified from 104 patients (67% male). Mean age at atrial switch was 22.1 months; mean age of PAH diagnosis was 29.3 years. Functional class improved from a baseline mean of 3.3 to 1.8 on treatment (p=0.001). No adverse events were associated with treatment. 3 of 4 patients initially referred for heart-lung transplant no longer require transplantation. CONCLUSIONS: PAH is a late complication of the atrial switch procedure for dTGA, affecting 5.7% of our dTGA atrial switch population, with a higher incidence in female patients. In this cohort, pulmonary arterial vasodilator therapy was well tolerated and improved functional status.

Oral citrulline as arginine precursor may be beneficial in sickle cell disease: early phase two results.

L-Arginine may be a conditionally essential amino acid in children and adolescents with sickle cell disease, particularly as required substrate in the arginine-nitric oxide pathway for endogenous nitrovasodilation and vasoprotection. Vasoprotection by arginine is mediated partly by nitric oxide-induced inhibition of endothelial damage and inhibition of adhesion and activation of leukocytes. Activated leukocytes may trigger many of the complications, including vasoocclusive events and intimal hyperplasias. High blood leukocyte counts during steady states in the absence of infection are significant laboratory risk factors for adverse complications. L-Citrulline as precursor amino acid was given orally twice daily in daily doses of approximately 0.1 g/kg in a pilot Phase II clinical trial during steady states in four homozygous sickle cell disease subjects and one sickle cell-hemoglobin C disease patient (ages 10-18). There soon resulted dramatic improvements in symptoms of well-being, raised plasma arginine levels, and reductions in high total leukocyte and high segmented neutrophil counts toward or to within normal limits. Continued L-citrulline supplementation in compliant subjects continued to lessen symptomatology, to maintain plasma arginine concentrations greater than control levels, and to maintain nearly normal total leukocyte and neutrophil counts. Side effects or toxicity from citrulline were not experienced. Oral L-citrulline may portend very useful for palliative therapy in sickle cell disease. Placebo-controlled, long-term trials are now indicated.

Heart murmurs in pediatric patients: when do you refer?

Many normal children have heart murmurs, but most children do not have heart disease. An appropriate history and a properly conducted physical examination can identify children at increased risk for significant heart disease. Pathologic causes of systolic murmurs include atrial and ventricular septal defects, pulmonary or aortic outflow tract abnormalities, and patent ductus arteriosus. An atrial septal defect is often confused with a functional murmur, but the conditions can usually be differentiated based on specific physical findings. Characteristics of pathologic murmurs include a sound level of grade 3 or louder, a diastolic murmur or an increase in intensity when the patient is standing. Most children with any of these findings should be referred to a pediatric cardiologist.

Interactive telecardiology for the evaluation of heart murmurs in children.

OBJECTIVE: To study the accuracy, patient satisfaction, and cost of telecardiographic evaluations of pediatric patients. MATERIALS AND METHODS: Patients referred to a rural pediatric cardiology outreach clinic were examined in person by a pediatric cardiologist. A second pediatric cardiologist who had no knowledge of the findings of face-to-face examination reevaluated the same patients utilizing a 768-Kbps telemedicine system. Any additional testing was performed by personnel who had no knowledge of the face-to-face evaluation. The main outcome measures included the final cardiac diagnosis, frequency of additional tests such as electrocardiography, (ECG) echocardiography (ECHO), and patient satisfaction. RESULTS: The diagnosis was agreed upon in 19 of the 21 patients studied. Two patients with small ventricular septal defects were missed during the telemedicine evaluation. The utilization rates of additional studies for both the face-to-face cardiologist and the telemedicine cardiologist were not significantly different. Patient satisfaction with the telemedicine encounter was good. CONCLUSIONS: Telemedicine appears to be effective and useful for the cardiac evaluation of pediatric patients. In spite of high data-transfer rates, differences between telemedicine and face-to-face patient encounters were observed.

Fatal obliterative coronary vasculitis in Kawasaki disease.

We report a unique case of Kawasaki disease with late sudden death from obliteration of the lumen of the full length of the left anterior descending coronary artery. Sequential echocardiograms showed early uniform coronary dilatation that resolved before sudden death. The implications of obliterative "healing" of coronary ectasia are unknown.

Normal fetal cardiac dimensions obtained by perpendicular imaging.

This study provides normal fetal cardiac dimensional data in a large patient group over a wide range of gestational ages. Perpendicular imaging decreased lateral resolution error, resulting in normal values with narrower confidence limits than in prior studies.

Acute myocardial infarction in a 16-year-old boy with no predisposing risk factors.

Chest pain in the pediatric age group is a common presentation to the emergency department and rarely signifies underlying cardiopulmonary pathology. However, when chest pain occurs in association with symptoms such as dyspnea, diaphoresis, or syncope/near-syncope, a cardiac etiology must be urgently considered. We present the case of an otherwise healthy adolescent male patient with no discernible risk factors for coronary artery disease or other heart disease who experienced a myocardial infarction.

[Congenital diseases of the aorta]. / Enfermedades congénitas de la aorta.

Congenital diseases of the aorta may be divided into three main groups. The most common group includes diseases which obstruct blood flow to the distal circulatory system. The second category includes those diseases which obstruct either the trachea or the esophagus. A third category of congenital diseases of the aorta includes abnormalities of the mechanical composition of the aorta. The major clinical manifestations included in each of these groups will be discussed.

Progressive pulmonary venous obstruction and pulmonary interstitial fibrosis associated with tetralogy of Fallot.

Stenosis of individual pulmonary veins is a rare condition associated with a very high mortality. The present report is the first known case of progressive pulmonary venous obstruction associated with the tetralogy of Fallot. This clinical and anatomical study suggests that initial dynamic and possibly reversible occlusion occurs at the junction of the pulmonary vein and left atrium. Anatomical lesions in pulmonary veins then develop, possibly secondary to functional stenosis. The usually fatal outcome of these cases is due to the development of fixed pulmonary venous occlusion and possibly pulmonary interstitial fibrosis. The rapid progression of pulmonary venous stenosis strongly suggests that discrete veno-atrial stenosis should be surgically corrected as early as possible to prevent the irreversible diffuse pulmonary venous obstruction associated with an invariably fatal prognosis.

Congestive heart failure in neonates due to intracranial arteriovenous malformation: endovascular treatment.

Newborns with intracranial arteriovenous malformations and congestive heart failure have an extremely poor prognosis. This report describes two infants with intracranial arteriovenous malformations and severe congestive heart failure successfully treated in the newborn period with endovascular embolization. Both infants had immediate improvement in symptoms and both had second embolization procedures performed. Ventriculoperitoneal shunting was necessary in both children because of progressive hydrocephalus. At follow-up of more than 4 years, neither patient has any sign of congestive heart failure, and one is developmentally normal.

Echocardiographic correlates of survival in severe bronchopulmonary dysplasia.

To define potential echocardiographic correlates of survival in infants with severe bronchopulmonary dysplasia (BPD), a retrospective analysis of echocardiograms was performed. Between 1982 and 1986, 27 infants with severe BPD had at least two echocardiographic studies. Echocardiograms were divided into early (less than 30 days of age), intermediate (45 to 120 days of age), and late (more than 145 days of age) periods, and survivors were compared with patients who subsequently died of causes related to BPD. Right ventricular size did not differ between survivors and nonsurvivors in any of the periods. Nonsurvivors had significantly smaller left ventricular internal dimensions than survivors in both the middle and late periods. Noninvasive estimates of pulmonary artery pressure (the right ventricular pre-ejection period/right ventricular ejection time ratio) did not differ between survivors and nonsurvivors until the late period. These data suggest that measurements of left ventricular size may have value in predicting survival of infants with severe BPD.

Complete transposition of the great arteries: treatment in the current era.

Transposition of the great arteries usually can be diagnosed by fetal echocardiography, which is important because the arterial switch operation, currently the treatment of choice, must be performed very early in life. The results of the arterial switch operation have been good to date. The dilemma remains, however, whether a fetus in whom a diagnosis of transposition is made should be aborted or treated surgically soon after delivery.