Fatal voluntary salt intake resulting in the highest ever documented sodium plasma level in adults (255 mmol L-1): a disorder linked to female gender and psychiatric disorders.

Excessive ingestion of salt is a well-recognized cause of hypernatraemia in children, is uncommonly recognized in debilitated elderly persons, but is rarely diagnosed in healthy, independent adults. We report a case of fatal salt poisoning in a 20-year-old lady who suffered of post-natal depression and ingested large quantities of salt as part of exorcism ritual. She presented with the highest ever documented serum sodium level of 255 mmol L(-1), associated with severe neurological impairment that was unresponsive to aggressive hypotonic fluid replacement. Post-mortem examination ruled out any other possible probable cause of death. The medical literature was reviewed, and 16 previous cases of severe hypernatraemia in adults secondary to excessive salt ingestion were retrieved. Common features of all reported cases included female gender (95% of cases) and evidence of underlying cognitive or psychiatric disorders (all reported cases). We conclude that women with documented cognitive or psychiatric disorders, in particular depression, are susceptible for psychogenic salt poisoning. Awareness should be raised to the potentially life-risking use of salty beverages as emetics or as part of 'exorcism' rituals.

The ongoing influence of staff training on the performance of radiofrequency catheter ablation.

The aim of this study was to assess whether the performance of RF catheter ablations continues to improve by further staff training once an initial success rate of > 90% has been achieved. Two hundred and ninety-five procedures of SVT catheter ablation using RF energy were studied. Atrial tachycardia and atrial flutter substrate ablations were not included. The procedures were performed during a 4-year period by the same physician and nurse, who had previous training in these procedures. The 4-year period was subdivided into four consecutive 1-year periods in which 69, 72, 68, and 86 procedures were performed. The outcome, recurrence rate, and duration of the curative procedure were compared among the four periods. There was no significant difference in the initial success rate among the four periods. The recurrence rate decreased from 21.74% to 13.95% (P < 0.05). The duration of the curative procedure decreased from 93.7 +/- 78.4 minutes to 39.1 +/- 32.2 minutes (P < 0.001), and the fluoroscopic time decreased from 25.5 +/- 22.3 minutes to 11.3 +/- 8.2 minutes (P < 0.001). These results were similar when accessory pathway and selective AV nodal pathways ablations were separately evaluated. Following the initial staff training, during which the expected 80%-90% success rate is achieved, additional training will reduce the recurrence rate and the duration of the procedures at a similar level of success.

Effect of delayed radiation therapy on local control in breast conservation therapy.

PURPOSE: To assess local control when radiation therapy is delayed to complete chemotherapy in breast conservation therapy. MATERIALS AND METHODS: Breast conservation therapy was performed in 310 cases in 297 patients (aged 24-85 years) with stage 0-II breast cancer. Adjuvant chemotherapy was used in 76 cases. The authors analyzed the time between diagnosis and radiation therapy and correlated these findings with local control of disease. RESULTS: The time between diagnosis and radiation therapy in the 247 cases treated without chemotherapy-related delay was 2-59 weeks (mean, 8 weeks). The interval in the 63 cases with chemotherapy-related delay was 12-63 weeks (mean, 31 weeks; P < .001). Ten of the 11 cases with an in breast relapse were in the group treated without a delay (P = .57). CONCLUSION: Delaying radiation therapy for chemotherapy does not compromise local control.

A new methodology for non-invasive clinical assessment of cardiovascular system performance and of ventricular-arterial coupling during stress.

The objective of the study was to develop a non-invasive method for the quantitative evaluation of cardiovascular performance and ventricular-arterial (VA) coupling during varying physiological states. VA-coupling was represented by the ratio between the arterial and ventricular elastances-Ea/Ees. Approximate indices of the relative change of Ees and VA-coupling during stress were developed and tested. These indices can be evaluated directly from non-invasive measurements of ejection fraction values (for VA-coupling) and measurements of stroke volumes and systolic and diastolic arterial pressures (for Ees). Additional relative indices can be evaluated from these data (e.g., stroke work, cardiac output) to yield a complete representation of the cardiovascular response to stress. The present methodology was applied to assess the exercise stress response in healthy subjects (H, n = 8) and in patients with left ventricular dysfunction (n = 24). Left ventricular volumes were determined by nuclear angiography and arterial pressures were measured non-invasively by a new, validated method. Using published data obtained invasively, we found that the relative indices of Ees and VA-coupling showed a high correlation with the invasive ones (r > 0.8, P < 0.01). The patients were subgrouped by their maximal exercise capacitance (P2-50W, P3-75W). At rest, the two patient groups had similar ejection fraction values (45 +/- 15% and 48 +/- 16%), which were significantly different from those of the healthy subjects (66 +/- 7%, P < 0.05). During stress, a larger increase in stroke work and cardiac output was found in the healthy subjects. All three groups showed similar relative increases in Ees and heart rate, but relative Ea increased in P2 and decreased in H, while the opposite was found for the end-diastolic volume. The relative VA-coupling index in P2 was significantly larger than that in P3 and H (P < 0.05). The present non-invasively based indices can be used to quantitatively monitor the individual cardiovascular response to stress testing or drug interventions and to evaluate the importance of VA-coupling in the clinical setting.

Detection of cholesterol associated with calcium mineral using confocal fluorescence microscopy.

BACKGROUND: Cholesterol and calcium are prominant components within human atherosclerotic lesions. Both accumulate predominantly within the central core region of lesions. Because of similarities in some crystallographic faces of cholesterol monohydrate and calcium apatite, it has been previously proposed that deposition of one may nucleate the deposition of the other. EXPERIMENTAL DESIGN: In this study, we have used the technique of confocal fluorescence microscopy to assess the spatial orientation of cholesterol in association with calcium mineral. Localization of cholesterol within mineral was carried out by staining cholesterol with the fluorescent probe, filipin. RESULTS: With this technique, it was possible to localize cholesterol associated with the surface of hydroxyapatite seeds, cholesterol incorporated within calcium phosphate-cholesterol agglomerates produced in vitro, and cholesterol within apatite isolated from human atherosclerotic lesions. CONCLUSIONS: The presence of cholesterol within the center of calcified granules from atherosclerotic plaque suggests that cholesterol or associated lipids may act to nucleate the deposition of apatite. Confocal fluorescence microscopy should be a useful technique by which to study the relationship of cholesterol associated with calcium minerals that occur not only in atherosclerotic blood vessels, but also in gallstones, and calcified cardiac valves.

Effects of nisoldipine on myocardial ischemia during exercise and during daily activity.

The antiischemic properties of nisoldipine, a dihydropyridine calcium antagonist, were assessed in a multicenter, double-blind, placebo-controlled trial by repeated exercise testing and 72-hour ambulatory electrocardiographic monitoring in 82 patients with coronary artery disease. Patients with positive treadmill stress test results and greater than or equal to 2 ischemic episodes per 24 hours were included in this study. Administration of all chronic antiischemic medications except beta blockers were discontinued. During the first week all patients received placebo twice daily. During the second and third weeks, 41 patients received nisoldipine 10 mg and 41 patients received placebo twice daily. In the placebo group there were no changes in exercise parameters or in ambulatory electrocardiographic parameters. In the nisoldipine group, exercise duration increased from 403 to 448 seconds (p = 0.0035), time to 1 mm of ST depression increased from 224 to 298 seconds (p = 0.002), time to pain increased from 241 to 321 seconds (p = 0.01), and maximal ST depression was reduced from 2.6 to 2.3 mm (p = 0.002). Among the ambulatory electrocardiographic parameters in the nisoldipine group, only the number of episodes was reduced, from 14.4 to 11.6 (p = 0.0013) per patient. There was no significant reduction in total ischemic time (132 vs 120 minutes per patient). No significant side effects were observed. This is the largest clinical trial to date on the effects of nisoldipine on myocardial ischemia. The results indicate that nisoldipine was effective in improving all exercise parameters and only partially effective in suppressing ischemia during daily activity.

Changes in ventricular function and coronary stenosis after successful intravenous thrombolysis in acute myocardial infarction.

Temporal changes in residual stenosis in the infarct-related coronary artery and ventricular function were studied in 30 consecutive patients with an acute myocardial infarction who received rapid, high dose intravenous infusions of streptokinase within 4 h of pain onset. Patients were studied 6 days and 3.9 +/- 1.3 months after the acute episode. Inferior infarction, early thrombolysis (less than 1.5 h after pain onset) and adequate reperfusion (less than 75% residual stenosis in the infarct-related coronary artery) were associated with smaller left ventricular infarcts, smaller ventricular volumes and better ventricular function. Residual stenosis tended to increase with time and in 6 patients the artery closed completely (1 with an overt clinical episode). Ventricular function and volumes improved progressively in patients with good initial function and less residual stenosis in the infarct-related coronary artery.