Efficacy of a Mouthwash Containing CHX and CPC in SARS-CoV-2-Positive Patients: A Randomized Controlled Clinical Trial.

Soon after the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, preprocedural mouthwashes were recommended for temporarily reducing intraoral viral load and infectivity of individuals potentially infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to protect medical personnel. Particularly, the antiseptic cetylpyridinium chloride (CPC) has shown virucidal effects against SARS-CoV-2 in vitro. Therefore, the aim of this randomized controlled clinical trial was to investigate the efficacy of a commercially available mouthwash containing CPC and chlorhexidine digluconate (CHX) at 0.05% each in SARS-CoV-2-positive patients as compared to a placebo mouthwash. Sixty-one patients who tested positive for SARS-CoV-2 with onset of symptoms within the last 72 h were included in this study. Oropharyngeal specimens were taken at baseline, whereupon patients had to gargle mouth and throat with 20 mL test or placebo (0.9% NaCl) mouthwash for 60 s. After 30 min, further oropharyngeal specimens were collected. Viral load was analyzed by quantitative reverse transcriptase polymerase chain reaction, and infectivity of oropharyngeal specimens was analyzed by virus rescue in cell culture and quantified via determination of tissue culture infectious doses 50% (TCID50). Data were analyzed nonparametrically (α = 0.05). Viral load slightly but significantly decreased upon gargling in the test group (P = 0.0435) but not in the placebo group. Viral infectivity as measured by TCID50 also significantly decreased in the test group (P = 0.0313), whereas there was no significant effect but a trend in the placebo group. Furthermore, it was found that the specimens from patients with a vaccine booster exhibited significantly lower infectivity at baseline as compared to those without vaccine booster (P = 0.0231). This study indicates that a preprocedural mouthwash containing CPC and CHX could slightly but significantly reduce the viral load and infectivity in SARS-CoV-2-positive patients. Further studies are needed to corroborate these results and investigate whether the observed reductions in viral load and infectivity could translate into clinically useful effects in reducing COVID-19 transmission (German Clinical Trials Register DRKS00027812).

Durable memories and efficient neural coding through mnemonic training using the method of loci.

Mnemonic techniques, such as the method of loci, can powerfully boost memory. We compared memory athletes ranked among the world's top 50 in memory sports to mnemonics-naïve controls. In a second study, participants completed a 6-week memory training, working memory training, or no intervention. Behaviorally, memory training enhanced durable, longer-lasting memories. Functional magnetic resonance imaging during encoding and recognition revealed task-based activation decreases in lateral prefrontal, as well as in parahippocampal and retrosplenial cortices in both memory athletes and participants after memory training, partly associated with better performance after 4 months. This was complemented by hippocampal-neocortical coupling during consolidation, which was stronger the more durable memories participants formed. Our findings advance knowledge on how mnemonic training boosts durable memory formation through decreased task-based activation and increased consolidation thereafter. This is in line with conceptual accounts of neural efficiency and highlights a complex interplay of neural processes critical for extraordinary memory.

Adherence to oral anticoagulant treatment and risk factor assessment six months after DC-conversion of atrial fibrillation.

Objective. We wanted to study the adherence of oral anticoagulant treatment in patients 6 months after elective DC-cardioversion and to observe possible increases in CHA2DS2-VASc scores and new adverse outcomes. Design. Consecutive patients admitted for elective DC-cardioversion at Haukeland University Hospital during the period from June 2017 to April 2018 were screened. Only patients who had a DC-cardioversion performed were included. Baseline information was collected from hospital records and follow up information was gathered through a structured phone interview and the prescription database. Results. Of the 125 patients screened, 38 were excluded as DC-cardioversion was not performed. The included patients were contacted 6 months later, out of whom 77 (84%) responded. Three patients had discontinued oral anticoagulation therapy, but only one patient had done so in violation of Guidelines. Two patients had continued oral anticoagulant treatment despite lack of indication. Of the responding patients 89% were compliant, estimated by a Proportion of Days Covered > 80%. Three patients experienced a thromboembolic event, despite being on anticoagulation. The mean CHA2DS2-VASc score increased from 3.0 ± 1.4 to 3.3 ± 1.5, (p < .001). Less than half maintained sinus rhythm, the remaining had either atrial fibrillation (n = 30, 40%) or were unsure of their current rhythm (n = 9, 12%). A third received new cardiac interventions during follow up. Conclusion. We found an excellent adherence to Guidelines recommended therapy amongst our patients. CHA2DS2-VASc scores increased significantly during the 6-month observation period. From this we conclude there is a need for structured follow up to assess new risk factors.

Static patella tilt and axial engagement in knee extension are mainly influenced by knee torsion, the tibial tubercle-trochlear groove distance (TTTG), and trochlear dysplasia but not by femoral or tibial torsion.

PURPOSE: The aim of this study was to investigate the association of femoral (FT), tibial (TT), and knee torsion (KT) on the patella tilt (PT), the axial engagement index (AEI), and the tibial tuberosity-trochlear groove distance (TTTG). METHODS: Femoral torsion, tibial torsion, knee torsion, patella tilt, the axial engagement index, the TTTG, and trochlear dysplasia were retrospectively evaluated on 59 patients suffering from recurrent patella instability or anterior knee pain with 118 torsional lower limb magnetic resonance imaging studies. RESULTS: FT and TT did not show any significant associations with TTTG, PT, and AEI (n.s.). KT was significantly associated with a higher TTTG, higher PT, and lower AEI (all, p < 0.001). Higher grade trochlear dysplasia was associated with a higher PT and lower AEI (both, p < 0.001). The Dejour classification showed no significant association with FT, TT, KT, and TTTG (n.s.). All measurement parameters showed an excellent interrater agreement (ICC 0.89-0.97). CONCLUSIONS: Static patella tilt and patellofemoral axial engagement in knee extension are mainly influenced by knee torsion, TTTG, and trochlear dysplasia but not by femoral or tibial torsion. These findings help to understand the underlying reasons for the patella position in knee extensions in CT and MRI investigations in patients suffering from patella instability and patellofemoral pain syndrome. LEVEL OF EVIDENCE: III.

[Reconstruction of the medial patellofemoral ligament using autologous gracilis tendon in an implant-free technique on the patellar side]. / Rekonstruktion des medialen patellofemoralen Ligaments mit autologer Grazilissehne in patellarseitig implantatfreier Technik.

OBJECTIVE: Anatomic reconstruction of the medial patellofemoral ligament using autologous gracilis tendon in an implant-free technique on the patellar side to regain patellofemoral stability. INDICATIONS: Recurrent dislocations, primary dislocation with high risk of recurrence, and dislocations with (osteo-)chondral flake fractures. As combined approach together with other procedures (trochleoplasty, tibial tubercle osteotomy). Revisions. CONTRAINDICATIONS: As an isolated procedure in patients with high degrees of trochlear dysplasia, chronic dislocation of the patella, and patellofemoral maltracking without instability. SURGICAL TECHNIQUE: Harvesting of the gracilis tendon. Drilling of a V-shaped tunnel with a special aiming device in anatomic position on the medial side of the patella. Drilling of a femoral tunnel in anatomic position under fluoroscopic control. Passage of the graft, arthroscopic-guided tensioning, and femoral fixation with a biodegradable interference screw. POSTOPERATIVE MANAGEMENT: Partial weight bearing (20 kg) for 1-2 weeks. No limitation in range of motion. No orthosis. Specific sports allowed after approximately 3 months. RESULTS: Perioperative complications associated specifically with the technique were observed in 1.0% (7 of 729 cases). In a series of 72 consecutive cases from May 2010 to October 2010, the following were recorded after 4.0 ± 0.1 years: recurrent dislocations in 3.2%, a Tegner activity score of 5.1 ± 1.8, and subjective satisfaction in 92% (follow-up rate 87.5%). No fracture of the patella was seen in any of our patients.

Laparotomy closure using an elastic suture: a promising approach.

BACKGROUND: Midline laparotomy wound failure like burst abdomen remains one of the major complications after abdominal surgery. The use of sutures with a closer resemblance to abdominal wall physiology, like elastic threads, could decrease the risk of these complications occurring. Thus, we evaluated the possibility of using a new elastic thread composed of thermoplastic polyurethane (TPU) as a suture for the closure of midline laparotomies compared to conventionally used polypropylene (PP) in a rabbit model. METHODS: The elastic TPU thread was processed and tensile tests were performed. Twenty female chinchilla rabbits underwent midline laparotomy. They were randomized to a TPU and a PP group depending on the suture used for fascia closure. After 7 or 21 days, the abdominal walls were assessed macroscopically for wound healing complications and were explanted for histopathological investigation. RESULTS: Tensile tests showed a mean elastic elongation of 55.5% and a sufficient material strength of the TPU thread. In animal experiments, there was no difference between the groups at 7 days; however, the TPU suture showed significantly less CD68 positive cells (p < 0.001) and a higher collagen I/III ratio (p = 0.011) than PP did after 21 days. The amount of apoptotic cells was significantly elevated in the TPU group (p = 0.007) after 21 days. No differences were found concerning granuloma size and number of Ki67-positive cells. CONCLUSIONS: The newly developed TPU thread shows promising tensile characteristics. Midline laparotomy closure is feasible and safe in a rabbit model. Immunohistochemistry indicates similar biocompatibility and wound healing after implantation compared to PP after 21 days. To confirm these findings and to proof long-term capability further studies need to be conducted.

Mid term results with the curved modular tapered, fluted titanium Revitan stem in revision hip replacement.

We report our experience of revision total hip replacement (THR) using the Revitan curved modular titanium fluted revision stem in patients with a full spectrum of proximal femoral defects. A total of 112 patients (116 revisions) with a mean age of 73.4 years (39 to 90) were included in the study. The mean follow-up was 7.5 years (5.3 to 9.1). A total of 12 patients (12 hips) died but their data were included in the survival analysis, and four patients (4 hips) were lost to follow-up. The clinical outcome, proximal bone regeneration and subsidence were assessed for 101 hips. The mean Harris Hip Score was 88.2 (45.8 to 100) after five years and there was an increase of the mean Barnett and Nordin-Score, a measure of the proximal bone regeneration, of 20.8 (-3.1 to 52.7). Five stems had to be revised (4.3%), three (2.9%) showed subsidence, five (4.3%) a dislocation and two of 85 aseptic revisions (2.3%) a periprosthetic infection. At the latest follow-up, the survival with revision of the stem as the endpoint was 95.7% (95% confidence interval 91.9% to 99.4%) and with aseptic loosening as the endpoint, was 100%. Peri-prosthetic fractures were not observed. We report excellent results with respect to subsidence, the risk of fracture, and loosening after femoral revision using a modular curved revision stem with distal cone-in-cone fixation. A successful outcome depends on careful pre-operative planning and the use of a transfemoral approach when the anatomy is distorted or a fracture is imminent, or residual cement or a partially-secured existing stem cannot be removed. The shortest appropriate stem should, in our opinion, be used and secured with > 3 cm fixation at the femoral isthmus, and distal interlocking screws should be used for additional stability when this goal cannot be realised.

Searching for light dark matter with the SLAC millicharge experiment.

New sub-GeV gauge forces ("dark photons") that kinetically mix with the photon provide a promising scenario for MeV-GeV dark matter and are the subject of a program of searches at fixed-target and collider facilities around the world. In such models, dark photons produced in collisions may decay invisibly into dark-matter states, thereby evading current searches. We reexamine results of the SLAC mQ electron beam dump experiment designed to search for millicharged particles and find that it was strongly sensitive to any secondary beam of dark matter produced by electron-nucleus collisions in the target. The constraints are competitive for dark photon masses in the ~1-30 MeV range, covering part of the parameter space that can reconcile the apparent (g-2)(µ) anomaly. Simple adjustments to the original SLAC search for millicharges may extend sensitivity to cover a sizable portion of the remaining (g-2)(µ) anomaly-motivated region. The mQ sensitivity is therefore complementary to ongoing searches for visible decays of dark photons. Compared to existing direct-detection searches, mQ sensitivity to electron-dark-matter scattering cross sections is more than an order of magnitude better for a significant range of masses and couplings in simple models.

Arrested blood flow during false aneurysm formation in the carotid arteries of cattle slaughtered with and without stunning.

The time to onset of arrested blood flow and the size of false aneurysms in the severed carotid arteries were assessed in 126 cattle during halal slaughter without stunning. Thirty six cattle (29%) showed early arrest of blood flow. In 6%, both the left and right carotid arteries in the same animal stopped bleeding before 60s had elapsed following the neck cut. The time to early arrested blood flow was on average 21s, and this was accompanied by enlargement with false aneurysms which occluded the arteries. In the arteries which were still bleeding at 60s after the neck was cut the artery size was normal. Based on comparative data from different slaughter premises it appeared that making the cut in the neck at the first cervical vertebra instead of the second to fourth cervical vertebrae reduced the frequency of false aneurysm formation and early arrested blood flow. This was confirmed in a separate controlled trial where 100 cattle were stunned with a captive bolt and the arteries were examined following neck cutting at either the C1 or C3 positions.

[Right-sided prosthetic cardiac valve thrombosis: value of cinefluoroscopy in the diagnosis and follow-up of thrombolytic treatment]. / Rechtsseitige Kunstklappenthrombose: Bedeutung der Klappendurchleuchtung für Diagnose und Kontrolle einer thrombolytischen Therapie.

HISTORY: A 33-year-old woman (Pt. A) with a prosthetic cardiac valve in the pulmonary position [CarboMedics bileaflet valve, diameter 23 mm] as part of the repair of a tetralogy of Fallot 4 years previously, and a 51-year-old woman (Pt. B) with a prosthetic cardiac valve [St. Jude Medical bileaflet valve, diameter 31 mm] inserted in tricuspid position as replacement of a degenerated Hancock bioprosthetic valve inserted 15 years previously, 10 years after an episode of endocarditis, were admitted to hospital with dyspnea and chest pain and dyspnea and tachycardia, respectively. INVESTIGATIONS: Pt. A had a 3 - 4/6 crescendo-decrescendo systolic murmur and a 2/6 early diastolic decrescendo murmur over the 2nd to 4th right intercostal space (ICS), while Pt. B had a 3/6 holosystolic murmur and a 2 - 3/6 diastolic murmur over the 4th right ICS. Closing click was missing in both patients. Blood tests demonstrated an elevated LDH (404 U/l) in Pt. A and an elevated GGT (108 U/l) and fibrinogen (449 mg/dl) in Pt. B. Anticoagulation was below the therapeutic level, with an INR value of 1,65 and 1,93, respectively. The electrocardiogram showed sinus rhythm, right bundle branch block and an isoelectric ST-segment (Pt. A) and a typical high-frequency atrial flutter with a 2:1 block, right bundle branch block and terminal T-wave inversions in leads V1 to V5 (Pt. B). Cinefluoroscopy showed rigid and hypomobile leaflets as a result of prosthetic cardiac valve thrombosis. Doppler echocardiography confirmed the stenosis of the prosthetic valve in the pulmonary position (peak gradient 73 mm Hg, mean gradient 34 mm Hg) and the tricuspid position (mean gradient 8.48 mm Hg, peak gradient 16.73 mm Hg). TREATMENT AND COURSE: Both patients were treated with unfractionated heparin and urokinase single-bolus injection of 4400 U/kg over 10 min followed by an infusion of 4400 U/kg/h over 12 h. Both patients had an abnormal opening angle, which improved to a normal opening and closing angle. Doppler echocardiography demonstrated decreased peak (18.0 and 6.6 mm Hg, respectively) and median gradients (9.0 and 2.6 mm Hg, respectively). No further complications (such as bleeding, embolism, delayed surgical treatment, rethrombosis) had occurred, and both patients became asymptomatic. After oral anticoagulation in a therapeutic INR range for 12 and 4 months, respectively, prosthetic heart valve function continued to be normal in both patients. CONCLUSION: Thrombolysis appears to be an efficacious and safe treatment in patients with thrombosis of a prosthetic cardiac valve in the pulmonary or tricuspid position, and it may be used as first-line therapy. Cinefluoroscopy is a simple and accurate method both in the diagnosis of prosthetic cardiac valve thrombosis and in following the response to thrombolytic treatment.

[Chance finding of a bilateral central pulmonary embolism while using cardiac computed tomography for the clarification of a coronary anomaly]. / Zufallsbefund beidseitiger zentraler Lungenembolien bei kardialer Computertomographie zur Klärung einer Koronaranomalie.

HISTORY: A 42 year-old man reported transient breathlessness and chest pain on the first day after a four-hour flight. During the following five months the symptoms recurred four times. After another episode he went to an outpatient department for further assessment. INVESTIGATIONS: Blood tests demonstrated slightly elevated LDH (343 U/l) and also a minor increase of the D-dimers (710 microg/l). Hypercholesterolemia was also found (LDL-cholesterol 180 mg/dl). The rest of the blood tests, including the cardiac enzymes, were within normal limits. The electrocardiogram (ECG) showed sinus rhythm, heart rate 85 bpm and pre-terminal T-negativity in the precordial leads V1 to V3. Resting echocardiography and chest X-ray showed no significant abnormalities. The exercise ECG demonstrated no further ECG changes. However, because of the symptoms and a cardiovascular risk profile (family history, hypercholesterolemia and smoking) a coronary angiography was performed, which excluded coronary artery disease but revealed a so-called "right-sided single coronary artery", the left and right coronary arteries originating with a common stem from the right sinus of valsalva. To define the exact course of the left main coronary artery (whether in front of the pulmonary artery, between the two great arteries, retroaortic or septal) a contrast-enhanced cardiac computed tomography (CT) was performed, which demonstrated an anomalous position of the left main coronary artery in front of the pulmonary artery. Bilateral pulmonary embolism was an additional and unexpected finding. TREATMENT AND COURSE: Oral anticoagulation was initiated after a coagulopathy had been excluded. The ultrasonography of the leg did not demonstrate any thrombosis. There was no evidence of malignant disease. CONCLUSION: Mild symptoms and absence of right heart congestion do not exclude pulmonary embolism. Depending on the symptoms and history, pulmonary thrombembolism has to be considered, especially if cardiac or extra-cardiac causes have been eliminated. The diagnostic method of choice for the detection or exclusion of pulmonary embolism is contrast-enhanced multi-slice spiral CT.

Validation of the SWAP-200 for diagnosing psychostructural organization in personality disorders.

BACKGROUND: The aim of the study was to investigate the validity of the prototype-matching, empirically based 200-item Shedler-Westen Assessment Procedure (SWAP-200) and its clinical utility for describing underlying dimensions of psychostructural organization and functioning. SAMPLING AND METHODS: Patients (n = 306) from two psychoanalytic out-patient departments were included. Replicatory and exploratory factor analysis, correlation and discriminant validity statistics, and canonical correlation analysis were performed. RESULTS: Replicatory factor analysis failed to reproduce the identical original factorial structure. Standard factor analysis revealed an eight-factor solution displaying a dimensional description of psychostructural personality organization (high functioning - neurotic/inhibited - borderline/emotionally dysregulated - psychotic/dissocial). Discriminant validity exists across the sample owing to high/poor psychological functioning. Canonical correlation analysis does not support the replacement of the Structured Clinical Interview for DSM-IV, but provides relevant implications for refining DSM-IV axis II. CONCLUSIONS: Support is given for the SWAP instrument in describing dimensional higher-order personality organization and psychostructural functioning.

Structural parameters affecting the kinetics of RNA hairpin formation.

There is little experimental knowledge on the sequence dependent rate of hairpin formation in RNA. We have therefore designed RNA sequences that can fold into either of two mutually exclusive hairpins and have determined the ratio of folding of the two conformations, using structure probing. This folding ratio reflects their respective folding rates. Changing one of the two loop sequences from a purine- to a pyrimidine-rich loop did increase its folding rate, which corresponds well with similar observations in DNA hairpins. However, neither changing one of the loops from a regular non-GNRA tetra-loop into a stable GNRA tetra-loop, nor increasing the loop size from 4 to 6 nt did affect the folding rate. The folding kinetics of these RNAs have also been simulated with the program 'Kinfold'. These simulations were in agreement with the experimental results if the additional stabilization energies for stable tetra-loops were not taken into account. Despite the high stability of the stable tetra-loops, they apparently do not affect folding kinetics of these RNA hairpins. These results show that it is possible to experimentally determine relative folding rates of hairpins and to use these data to improve the computer-assisted simulation of the folding kinetics of stem-loop structures.

Coronariografía no invasiva mediante tomografía axial computada multicorte / 16 detector computed tomagraphy for coronary angiography

Antecedentes: La tomografía axial computada de 16 detectores de las arterias coronarias (TAC Coronario) ha emergido recientemente como una alternativa diagnóstica a la coronariografía invasiva (CI). Objetivo: Estudiar la exactitud del TAC coronario de 16 detectores para pesquisar la presencia o ausencia de estenosis coronaria en distintos tipos de pacientes, mediante su comparación con la CI. Métodos: A un total de 55 pacientes (46 hombres, 9 mujeres, promedio 57 +/-12 años) en quienes se realizó una CI electiva, se les realizó un TAC coronario. Se analizó específicamente la presencia de lesiones 50 por ciento y se compararon estos resultados con los obtenidos mediante la CI cuantitativa. Resultados: Cincuenta pacientes requirieron beta bloqueo, obteniéndose una FC promedio de 57 lpm. En los segmentos principales se objetivaron 61 lesiones significativas por CI, de las cuales 52 (85,2 por ciento) fueron correctamente detectadas por el TAC coronario. La sensibilidad, especificidad, LH(+) y LH(-) del examen fueron 85 por ciento, 97 por ciento, 33 y 0.15, respectivamente. La presencia o ausencia de enfermedad coronaria significativa fue correctamente diagnosticada en 50 de los 55 pacientes (91 por ciento). Conclusión: El TAC coronario de 16 detectores es un examen sensible y específico para el diagnóstico de estenosis significativas de los segmentos principales del árbol coronario.

Background: Invasive coronary arteriography (ICA) is the gold standard to assess coronary artery stenosis. Sixteen detector computed tomography (Coronary CT) has recently been introduced as a less invasive diagnostic alternative. Aim: To assess the reliability of Coronary CT in detecting coronary stenosis among different types of patients by comparing the results with those obtained by ICA. Methods: 55 patients (age 57+/-12 years, 46 males) who underwent ICA had also a coronary CT. Beta blockade was used to obtain a heart rate < 65 beats per min. The presence of significant stenosis (•'3d50 percent of luminal diameter measured by quantitative angiography) was compared between methods.Results: Adequate coronary images were obtained in 53 of 55 patients with coronary CT; a total of 715 coronary segments were available for analysis. Fifty patients required beta blockade and the mean heart rate was 57 beats per min. Fifty-two out of 61 main segment stenosis were detected by coronary CT (85.2 percent). Sensitivity, specificity, LH+ and LH- of coronary CT were 85 percent, 97 percent, 33 and 0.15, respectively. The presence or absence of significant lesions was correctly diagnosed in 50 of the 55 patients (91 percent). Conclusion: 16 detector coronary CT is a sensitive and specific method to diagnose main segment significant coronary stenosis.

Reverse remodelling of systolic left ventricular contraction pattern by long term cardiac resynchronisation therapy: colour Doppler shows resynchronisation.

OBJECTIVE: To quantify long term effects of cardiac resynchronisation therapy (CRT) by biventricular pacing in patients with heart failure (HF). METHODS: Regional changes in left ventricular (LV) contraction patterns effected by CRT in 19 patients with HF (12 with ischaemia; mean (SD) age 66 (9) years) with bundle branch block were examined by colour Doppler tissue velocity imaging (c-TVI). Time differences during main systolic tissue velocity peak (SYS) were compared in the basal and mid LV interventricular septum and in the corresponding LV free wall segments. RESULTS: From baseline to long term (9.8 (3.0) months) CRT, ejection fraction increased from 21.8 (5.4)% to 30.8 (7.6)%, LV end diastolic diameter decreased from 7.6 (0.9) cm to 7.1 (0.8) cm, and end systolic diameter decreased from 6.4 (1.2) cm to 6.0 (1.2) cm (p < 0.05). LV peak tissue velocities were unchanged during follow up. At baseline, SYS in LV free wall was typically delayed by an average of 29 ms in the basal LV site and by 18 ms in the mid LV site. The regional movements of the LV free wall and interventricular septum were separated by an average of only 14 ms and -4 ms (p < 0.05) at the basal site and by -21 ms and -16 ms at the mid LV site during short term and long term CRT, respectively. CONCLUSIONS: The improved haemodynamic functions observed during CRT may be explained by a significant resynchronisation of the regional LV movement pattern during long term follow up.

[Rebound hyperplasia of the thymus with secondary intrathymic bleeding. Rare differential diagnosis of acute chest pain]. / Rebound-Hyperplasie des Thymus mit sekundärer Einblutung. Seltene Differenzialdiagnose des akuten Thoraxschmerzes.

HISTORY AND ADMISSION FINDINGS: A 41-year-old man was admitted, in reduced general condition, having for several hours experienced acute left chest pain and dyspnoea. On examination there was dullness on percussion over the base of the left lung with decreased breath sounds. At the age of 28 years he had been placed on peritoneal dialysis for renal failure due to congenital kidney aplasia. A year later he had been given a renal transplant, which had to be removed a year before admission because of transplant glomerulopathy. He had been on peritoneal dialysis since then. INVESTIGATIONS: Haemoglobin concentration, erythrocyte count and haematocrit gradually fell. A chest X-ray revealed a mediastinum widened to the left. Computed tomography demonstrated a blood-containing mediastinal tumour and a haemothorax. DIAGNOSIS, TREATMENT AND COURSE: A haemorrhagic mediastinal tumour was excised at thoracotomy. Histology of the specimen showed thymus hyperplasia with extensive fresh bleeding in the thymus. The postoperative course was without complication and the patient's exercise capacity returned to normal. CONCLUSION: Thymus hyperplasia with life-threatening spontaneous haemorrhage can occur after termination of immunosuppression following transplant removal.

Context-Oriented Model Development in Psychotherapy Planning ('COMEPP'): a useful adjunct to diagnosis and therapy of severe personality disorders.

OBJECTIVE: Pathogenous interpersonal (e.g. interfamilial) relationships and reference styles can compromise treatment efforts in severely disturbed (i.e. psychotic or borderline) patients. The integration of family- and individual-centred starting points may be useful in establishing interdisciplinary treatment concepts in these patients. Context-Oriented Model Development in Psychotherapy Planning (COMEPP) represents a diagnostic and therapy planning process, integrating both systemic and psychoanalytic conceptualizations. METHOD: COMEPP is exemplified by the case of a young man with psychotic personality disorder who had previously been unresponsive to pharmacological and psychological treatment. RESULTS: After psycho-dynamical conflicts (i.e. primitive projective processes from the patient's mother to her son) had been elucidated during the COMEPP process, a sufficient treatment setting could be established. CONCLUSION: COMEPP provides a psychotherapeutical approach to treatment planning on case-specific premises and may serve as an adjunct to concomitant pharmacological and psychological treatment strategies in so-called 'therapy refractory' patients.

Colour tissue velocity imaging can show resynchronisation of longitudinal left ventricular contraction pattern by biventricular pacing in patients with severe heart failure.

OBJECTIVE: To quantify ventricular resynchronisation by biventricular pacing using colour tissue Doppler velocity imaging (c-TVI). DESIGN AND PATIENTS: c-TVI shows regional tissue velocity profiles with a very high time resolution (10 ms). Eighteen patients were studied from an apical four chamber view at baseline and after a one month follow up of biventricular pacing. Regional left ventricular peak tissue velocities and regional time differences during the cardiac cycle were compared in the basal and mid interventricular septal segments of the left ventricle, and in the corresponding segments in the left ventricular free wall. RESULTS: From baseline to follow up, mean peak tissue velocities changed only during isovolumic contraction in the basal interventricular septum and the left ventricular free wall. At baseline the peak main systolic tissue velocities in the left ventricular free wall were typically delayed by an average of 42 ms in the basal left ventricular site and by 14 ms in the mid left ventricular site compared with the corresponding sites in the interventricular septum. After resynchronisation by biventricular pacing those regional movements were separated by an average of only 7 ms at the basal site, but there was still a 21 ms earlier movement of the left ventricular free wall in the mid left ventricular site. The diastolic movement pattern remained unchanged from baseline to follow up. CONCLUSIONS: c-TVI showed a significant asynchronous regional longitudinal movement of basal left ventricular sites at baseline. A change to a more synchronous longitudinal left ventricular movement pattern during biventricular pacing was demonstrated.

Pharmacodynamic and clinical trials of glycoprotein IIb/IIIa inhibitors and potential relationship of results to dosing.

Glycoprotein IIb/IIIa inhibitors have become the standard of care for patients undergoing percutaneous coronary intervention (PCI) and for those presenting with non-ST-segment elevation myocardial infarction (NSTE-ACS). Clinical effects of GP IIb/IIIa inhibitors in PCI and NSTE-ACS strongly correlate with potency, consistency, and durability of platelet aggregation inhibition. Under standardized conditions [light transmission aggregometry (LTA), 20 micromol adenosine diphosphate (ADP) as an agonist, and D-phenylalanyl-L-propyl-L-arginine chloromethyl ketone (PPACK) as an anticoagulant], we demand consistent platelet aggregation inhibition >80% during the time of PCI (initial balloon inflation), and during the entire duration of therapy in NSTE-ACS. The benefit of abciximab (bolus 0.25 mg/kg plus infusion 10 microg/kg/min) correlates with >80% inhibition of platelet aggregation during the intervention (PCI) and immediately thereafter (<6 hours). The absence of a benefit with abciximab in NSTE-ACS is most likely due to <80% inhibition during the major part of the infusion period (>6 hours). Tirofiban does not achieve >80% inhibition at the time of PCI at a dose of 10 microg/kg bolus plus 0.15 microg/kg/min infusion, and at a dose of 0.4 lg/kg/min loading infusion for 30 minutes plus 0.1 microg/kg/min maintenance infusion, the target value is only reached after 18 h. Eptifibatide (double-bolus 180 microg/kg 10 min apart, followed immediately by a 2.0 microg/kg/min infusion) provided an instant, consistent, and durable antiplatelet effect for the entire duration of infusion, and a significant clinical benefit in both PCI (non-ACS patients) and medically managed NSTE-ACS patients.