Mild Ventricular Dilatation Research Articles

Sonographic Association of Ventriculomegaly and Neural Tube Anomalies

Background: Ventriculomegaly is most common indicator of many of neural tube anomalies of intrauterine fetus. Presence of which has alarming sign for sonologist to have careful evaluation of fetus for other cranial and extra cranial anomalies. Aim: To evaluate the sonographic difference of fetal ventricle dilatation and neural tube anomalies. Study design: Cross Sectional study. Methodology: Female patients (n=1492) were enrolled in present study held at University Ultrasound Clinic, Green Town, University of Lahore as a reference placement for 6 months. Informed consent was taken from all of them. In this study, pregnant women who underwent ultrasound scanning between 18 and 40 weeks of gestational age were reviewed according to normal size of ventricles and dilatation of ventricles by per abdominal ultrasound having convex transducer with 3.5MHZ frequency. Results: A total of 1492 cases of pregnant women between gestational ages of 18-40 weeks were examined. Normal cases were 1485/1492(99.5%).Total 7-cases were found to have ventricle dilatation. Fetus with mild ventricular dilatation 1/7, with moderate ventricle dilatation were 4/7, 2/4 having moderate ventricle dilatation were associated with neural tube anomalies, severe ventricle dilatation was noted in 2/7, both these fetuses had neural tube anomalies. Conclusion: This study concluded that level of degree of dilatation increases the chances of abnormalities. Early detection provide better counseling opportunity for family to make decisions regarding their fetuses. Keywords: Neural tube defects, Ventriculomegaly, Gestation age and Ultrasonography.

Fully penetrant genetic mutation results in wide familial variability: a cardiac magnetic resonance focused report

Abstract Dilated cardiomyopathy (DCM) is a myocardial disorder characterized by ventricular dilation (LV or biventricular) and systolic dysfunction, with a broad etiological spectrum, comprising numerous genetic and non-genetic causes. Cardiac magnetic resonance (CMR) has become an important tool in guiding the etiological diagnosis in DCM. We present the case of a 37-years old man admitted to our department in order to investigate the diagnosis of DCM using CMR. Cine imaging showed mild left ventricular (LV) dilatation and moderate systolic (LV ejection fraction = 42%) dysfunction, but also apical hypertrabeculation meeting the criteria for non-compaction and late gadolinium enhancement (LGE) images revealed mid-wall fibrosis in the basal and midventricular segments of the inferior interventricular septum (IVS) – typical of non-ischemic DCM. Complete family history revealed the diagnosis of DCM in the mother of the patient and in the maternal grandfather, who had died at 87. After genetic testing of the index patient showed a pathogenic mutation in the TTN (titin) gene (c.79273A>T), cascade genetic testing followed, for his mother, sister, uncle and two cousins who all came back positive for the same mutation. CMR examination of the mother done 6 years prior demonstrated severe LV dilatation and systolic dysfunction (LV ejection fraction = 23%), LV non-compaction and mid-wall IVS fibrosis. CMR examination was performed for the other members of the family and discovered pathological findings in the uncle (normal LV volume and function, but focal mid-wall fibrosis in the inferior IVS) and the male cousin (LV non-compaction), while the female cousin had a normal exam. Using CMR and genetic testing, this case report proves the phenotypic heterogenicity of a completely penetrant titin mutation in the same family. Moreover, CMR is shown to be essential in DCM evaluation, having the ability to guide etiologic diagnosis and to detect alterations such as fibrosis and non-compaction in the absence of LV dilation or dysfunction.

Frameless radiosurgical third ventriculostomy: Technical report.

Background: We describe the technical report and results of the first image-guided, linear accelerator, frameless radiosurgical third ventriculostomy.Methods: We report a 20 years old man, with diplopia, balance disturbances, and limitation for gaze supraversion. Magnetic resonance imaging resonance imaging of the brain and cranial computed tomography showed showed a left thalamic-midbrain lesion that caused partial compression of the Silvio aqueduct and mild ventricular dilatation. The biopsy revealed the diagnosis of pleomorphic xanthoastrocytoma. Before radical treatment of the tumor with fractionated stereotactic radiotherapy, the patient underwent to frameless radiosurgical third ventriculostomy, on the TrueBeam STX® platform with the ExacTrac localization system. The target used was the one defined on the floor of the third ventricle, at the midpoint between the mammillary bodies and the infundibular recess. The prescription dose was 120 Gy, given using a monoisocentric technique of multiple noncoplanar circular arches. The geometric arrangement of the plan consisted of 15 arches, with a 4 mm cone, distributed over a 110° table.Results: There was symptomatic and image improvement two days after radiosurgery. On CT, a reduction in ventricular dilation was observed with a reduction in the Evans index from 0.39 (initial CT) to 0.29 (CT at 15 days). In 3.0T magnetic resonance image at 3 months, we showed the third ventriculostomy. There have been no treatment failures or complications.Conclusion: It is possible to effectively perform the frameless radiosurgical third ventriculostomy without associated morbidity in the short term.

A Rare Case of Choroid Plexus Papilloma of the Third Ventricle in an Adult

Colloid cysts are the commonest masses of the third ventricle. Third ventricle neoplasms are uncommon. They include tumors arising from the choroid plexus (papillomas, carcinomas), tumors arising from other than the choroid plexus (ependymomas, meningiomas), metastases, and lymphoma. Choroid plexus tumors usually occur in the lateral ventricle in children and fourth ventricle in adults, and often present with hydrocephalus. We herein describe the extremely rare occurrence of third ventricle choroid plexus papilloma in a 35-year-old man who presented to the emergency department with a long history of intermittent headaches, occasionally associated with photophobia. CT and MR imaging revealed a lobulated ovoid lesion in the third ventricle with minimal extension into the right lateral ventricle through the foramen of Monro, causing mild ventricular dilatation. Surgical resection was performed and histopathology revealed choroid plexus papilloma.

Clinical implications of idiopathic pulmonary arterial hypertension phenotypes defined by cluster analysis

>Despite advances in drug development, life expectancy in idiopathic pulmonary arterial hypertension (IPAH) remains unacceptable. Contemporary IPAH characterization is based on criteria that may not adequately capture disease heterogeneity and may be proposed as a possible explanation for why patient outcome is still unfavorable. The aim of this study was to apply cluster analysis to improve phenotyping of patients with IPAH and analyze long-term clinical outcome of derived clusters. Patients with IPAH from 2 referral centers (n = 252) were evaluated with clinical, hemodynamic, and echocardiographic assessment and cardiopulmonary exercise test. Patients were classified according to cluster analysis and followed for clinical worsening occurrence. The cluster analysis identified 4 IPAH phenotypes. Cluster 1 was characterized by young patients, mild pulmonary hypertension (PH), mild right ventricular (RV) dilation and high oxygen (O2) pulse; Cluster 2 by severe PH and RV dilation and high O2 pulse; and Cluster 3 by male patients, severe PH and RV dilation, and low O2 pulse. Cluster 4 patients were older and overweight, with mild PH and RV dilation and low O2 pulse. After a mean follow-up of 995 ± 623 days, 123 (48.8%) patients had clinical worsening. Cluster 1 patients presented the best prognosis, whereas Cluster 3 had the highest rates of clinical worsening. Compared with Cluster 1, risk of clinical worsening ranged from 4.12 (confidence interval [CI] 1.43-11.92; p = 0.009) for Cluster 4 to 7.38 (CI 2.80-19.40) for Cluster 2 and 13.8 (CI 5.60-34.0; p = 0.0001) for Cluster 3. Cluster analysis of clinical variables identified 4 distinct phenotypes of IPAH. Our findings underscore the high degree of disease heterogeneity that exists within patients with IPAH and the need for advanced clinical testing to define phenotypes to improve treatment strategy decision-making. CONDENSED ABSTRACT Idiopathic pulmonary arterial hypertension (IPAH) characterization is based on criteria that may not adequately capture disease heterogeneity. The aim of this study was to apply cluster analysis to improve phenotyping of IPAH. Patients with IPAH (n = 252) were evaluated with clinical, hemodynamic, and echocardiographic assessment and cardiopulmonary exercise test. Within the umbrella category of IPAH, it was the combination of mean pulmonary arterial pressure, right ventricular size, and oxygen pulse that further stratified patients into novel IPAH phenotypes that significantly associate with clinical worsening. These findings underscore the need for novel multidimensional IPAH phenotyping for improved patient care and trial quality.

P1502 A clinical case of mitral annulus disjunction syndrome revealed by cardiac MRI

Abstract A 39year old female patient with a family history of probable sudden cardiac death/long QT syndrome (sister died aged 36) was referred to our Arrhythmia/inherited cardiac conditions clinic. Patient was fit and well. She described occasional postural presyncope and some chest pain with stress. Not on any medication that could prolong QT. On examination she appeared well with normal heart sounds and no clinical signs of heart failure. Her ECG in clinic confirmed sinus rhythm with normal QTc at 418msec. There were U waves which may reflect late repolarisation of His Purkinje system. Diagnostic techniques and findings A 24-hour ECG tape to look at the average QT interval, an exercise tolerance test to look for appropriate shortening of QT interval with exercise and an echocardiogram to exclude significant structural abnormality were requested. The 24-hour ECG tape confirmed underlying sinus rhythm with multi-focal aberrant beats <1% of total. One symptom demonstrated short run of ventricular bigeminy. During the exercise tolerance test, QT interval was not obviously prolonged. There were frequent bifocal ventricular ectopic beats in recovery. The echocardiogram showed minor abnormality with mild left ventricular dilatation, otherwise normal findings. Patient referred for cardiac MRI In order to rule out any cardiomyopathy. Cardiac MRI did not show any prolapse on the 3 chamber cine. In addition, the inferior and inferolateral annulus showed thinning passing into the LV, which is a feature of some patients with mitral annulus disjunction syndrome. We went through the echocardiogram and in one single frame images are suspicious of focal P2 prolapse. Learning points: Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. It has been associated with mitral valve prolapse and sudden cardiac death. MAD is usually revealed with echocardiogram. In this case report we showed that CMR revealed a MAD previously missed by echo. Abstract P1502 Figure.

Abstract 760: Metabolic Syndrome Impairs Cardiac Remodeling During Pregnancy in Mice

Rationale: Due to the change of life style in the past decades, the incidence of metabolic syndrome (MetS) and obesity in women of childbearing age has been increased. Evidences have shown that complications during pregnancy, such as obesity and gestational diabetes, strongly link to future heart diseases. During normal pregnancy, the heart undergoes a physiological remodeling with mild ventricular dilation and hypertrophy. However, the effects of MetS on cardiac phenotype during pregnancy are not well understood. Moreover, animal models for MetS so far are not well established, which are usually species limited, gender limited and lack of translational significance. Thus, it’s important to develop an animal model which resembles the etiology of MetS in human beings. Objective: Establish a model of MetS in female C57BL/6J mice and determine the effects of MetS on cardiac remodeling during pregnancy. Methods and Results: To establish a mouse model of MetS, high fat (49% kcal)/high carbohydrates (HF-HC) diet were given to C57BL/6J female mice at the age of 8-week. Mice fed with normal diet (10% kcal fat) served as control. After 14 weeks feeding, mice fed with HF-HC diet showed significantly higher body weight and gonadal fat weight compared with control mice. Moreover, mice fed with HF-HC diet showed impaired glucose tolerance and higher serum total cholesterol level. The symptoms of obesity, impaired glucose tolerance and dyslipidemia suggest the development of MetS. Female mice after 14-week special diet feeding were subjected to breeding. Cardiac function was evaluated by echocardiography during pregnancy and 1-day post-partum, then the mice were terminated 1-day post-partum. Female mice that developed MetS showed impaired cardiac function and pathological remodeling during pregnancy. Moreover, mice fed with HF-HC diet showed more myocardium interstitial fibrosis accompanied with upregulation of fibrosis related genes in the heart compared with Ctrl diet. Conclusion: We’ve developed a mouse model of MetS in C57BL/6J mice strain with 14 weeks feeding of HF-HC diet, which resemble the western diet that affects human beings nowadays. Females that have MetS showed impaired cardiac function and pathological remodeling during pregnancy.

105 A presentation resembling transient global amnesia with underlying tako-tsubo cardiomyopathy and multifocal ischaemic stroke (with restricted diffusion in the left mesiotemporal lobe)

IntroductionWe present a case of a 65 year-old female with a presentation resembling transient global amnesia (TGA) with investigations revealing a Tako-tsubo cardiomoyopathy and multifocal punctate areas of restricted diffusion consistent with ischaemic stroke.MethodsSingle case report.ResultsA 65 year-old female presented altered behaviour with anterograde amnesia consistent with an episode of TGA. There was no clearly identifiable stressor to provoke this episode. The TGA-like symptoms persistent for 12 hours before the patient made a full recovery.During the presentation the patient complained of chest pain with elevated troponin. Cardiac investigation was notable for mild left ventricular dilation with mid- and apical hypokinesis on transthoracic echocardiogram and a normal coronary angiogram consistent with Tako-tsubo cardiomyopathy. Magnetic resonance imaging of the brain revealed multifocal infarcts including punctate foci of restricted diffusion within the left mesiotemporal lobe.ConclusionThis case is notable as it is rare to have a combined presentation with TGA-type symptoms with Tako-tsubo cardiomyopathy and multifocal ischaemia stroke.1 This is the first clinical case presentation involving the aforementioned triad and mesiotemporal lobe restricted diffusion. We hypothesise that the Tako-tsubo cardiomyopathy acted as the triggering event and the mesiotemporal lobe involvement caused the TGA-like symptoms thereby accounting for the clinical presentation and investigation findings. As mesiotemporal/hippocampal restricted diffusion may be seen with transient global amnesia,2 this case is of special interest mechanistically although we cannot exclude the alternative hypothesis that the episode of TGA resulted in the Tako-tsubo cardiomyopathy which subsequently caused the cardioembolic shower.ReferencesStollberger C, DeCillia N, Finsterer J. ‘Tako-tsubo cardiomyopathy with transient global amnesia and cerebellar embolic stroke triggered by existential fear.’Neurol Neurochir Pol 2018; 52(3):394–396.Enzinger C, Thimary F, Kapeller P, Ropele S, Schmidt R, Ebner F, Fazekas F. ‘Transient global amnesia: diffusion-weighted imaging lesions and cerebrovascular disease.’Stroke 2008;39(8):2219–2225.

Electrocardiographic and echocardiographic evaluation of a large cohort of peri-pubertal soccer players during pre-participation screening.

The early diagnosis of cardiac abnormalities in young athletes may be helpful not only to identify subjects potentially at risk of sudden cardiac death but also to prevent stress-related cardiac dysfunction and cardiovascular events during the life of these subjects. The aim of our study was to investigate the prevalence of cardiac abnormalities in a population of young male soccer players undergoing pre-participation screening through electrocardiogram and trans-thoracic echocardiography. All consecutive male football players undergoing pre-participation screening comprehensive of medical history, physical examination, 12-lead electrocardiogram and trans-thoracic echocardiography at the FMSI Sport Medicine Institute in Rome between January 2008-March 2009 were enrolled in the study. Overall, 2261 consecutive young athletes aged 12.4 ± 2.6 years were evaluated. Training-unrelated electrocardiogram abnormalities were observed in 65 (2.9%) athletes. Abnormal trans-thoracic echocardiography was observed in 102 athletes (4.5%), including two cases of hypertrophic cardiomyopathy, eight of mild left ventricular hypertrophy, six of mild left ventricular dilation and 17 of bicuspid aortic valve. An abnormal electrocardiogram was associated with anomalous trans-thoracic echocardiography in 11/65 (16.9%) cases. All athletes requiring sport disqualification were identified by electrocardiogram. Notably, among 2216 athletes with a normal electrocardiogram, 91 had abnormal trans-thoracic echocardiography, including six cases of left ventricular dilation and six of ventricular hypertrophy. In a wide population of peri-pubertal male athletes, evaluation of the electrocardiogram identified all cardiac diseases requiring sport disqualification. Trans-thoracic echocardiography alone allowed the identification of cardiac abnormalities potentially leading to cardiomyopathies or major cardiovascular events over time.

Rare case of anomalous right coronary artery from pulmonary artery (ARCAPA syndrome)

Anomalous right coronary artery from pulmonary artery (ARCAPA) is a rare congenital anomaly of right coronary artery, most of the patient are asymptomatic, although myocardial infarction and sudden cardiac arrest has been reported. Herein we present a 5 month old infant presented with chest infection, during routine examination cardiac murmur detected, anomalous right coronary artery from pulmonary artery suspected by transthoracic Echocardiography which showed dilated (4mm) left main stem of coronary artery with mild left ventricular dilatation, but the origin of right coronary artery couldn’t be detected. Coronary angiography done which confirm the diagnosis and the child successfully operated on for reimplantation of right coronary artery to the aortic cusp.

Abstract 364: Metabolic Syndrome Induced by High Fat/high Fructose Diet in C57bl/6 Mice Impaired Cardiac Remodeling During Pregnancy

Rationale: Due to the change of life style in the past decades, the incidence of metabolic syndrome (MetS) and obesity in women of childbearing age has been increased. Evidences have shown that complications during pregnancy, such as obesity and gestational diabetes, strongly link to future heart diseases. During pregnancy, the heart undergoes a physiological remodeling with mild ventricular dilation and hypertrophy. However, the effects of MetS on cardiac phenotype during pregnancy are not well understood. Moreover, animal models for MetS so far are not well established, which are usually species limited, gender limited and lack of translational significance. Thus, it’s important to develop an animal model which resembles the etiology of MetS in human beings. Objective: Establish a model of MetS in female C57BL/6J mice and determine the effects of MetS on cardiac remodeling during pregnancy. Methods and Results: To establish a mouse model of MetS, high fat (49% kcal)/high fructose (35.6% kcal) diet are given to C57BL/6J mice at the age of 8-week. Mice fed with normal diet (10% kcal fat) served as control. To better characterize the model within different genders, male mice are also subjected to the high fat/ high fructose (HFHF diet) and control diet. After 12 weeks feeding, mice fed with HFHF diet showed significantly higher body weight and gonadal fat weight compared with control mice in both genders. Also, mice fed with HFHF diet showed impaired glucose tolerance and higher serum total cholesterol level. However, the blood pressure showed no difference between groups in both genders. Overall, the symptoms of obesity, impaired glucose tolerance and dyslipidemia suggest the development of MetS. Female mice after 12-week special diet feeding will be subjected to breeding. Cardiac function is then evaluated by echocardiography before and during pregnancy. Female mice that developed MetS showed impaired cardiac function and pathological remodeling during pregnancy. Conclusion: We’ve developed a mouse model of MetS in both female and male C57BL/6J mice strain with 12 weeks feeding of HFHF diet, which resemble the western diet that affects human beings nowadays. Females that have MetS showed impaired cardiac function and pathological remodeling during pregnancy.

Case Study: An Incidental Finding of Left Ventricular Non-compaction (LVNC) in a Patient with a History of Alcoholism

A 52-year-old male patient was emitted to the hospital for alcohol withdrawal and pneumonia. A transthoracic echocardiogram (TTE) was ordered to rule out cardiomyopathy. The TTE showed mild left ventricular hypertrophy and dilation, moderate left atrial dilation, mild pulmonary hypertension, diastolic dysfunction and severe systolic dysfunction. The most unique finding was of significantly increased left ventricular trabeculations, characteristic to the condition known as Left Ventricular Non-compaction. Differential diagnoses’ were ruled out including apical thrombus, tumours, normal trabeculations, false tendons/aberrant bands and apical hypertrophy.

Clinical analysis of 30 cases of neonatal group B streptococcus sepsis

Objective To explore the clinical characteristics, treatment and prognosis of neonatal group B streptococcus (GBS) sepsis. Methods According to the onset time and clinical features of the patients, 30 cases of neonatal GBS sepsis in Department of Neonatology, Zhuhai People′s Hospital and ICU of Newborn of Maternity and Child Care Health Hospital of Guangxi from January 2013 to February 2015 were divided into the early-onset group (onset day of the patients ≤7 days) and late-onset group (onset day of the patients >7 days). The clinical manifestations, the examination results of laboratory, imaging examination, treatment and prognosis were retrospectively analyzed. Results Among the newborns diagnosed as neonatal GBS sepsis, there were 19 cases of early-onset sepsis and 11 cases of late-onset sepsis, including 17 males and 13 females, consisting of 24 term infants and 6 premature infants.The early-onset newborns were mainly diagnosed with respiratory symptoms like anhelation, groaning (73.7%, 14/19 cases), late-onset GBS sepsis with high fever (81.8%, 9/11 cases), high frequency of early-onset intraute-rine infection pneumonia (89.5%, 17/19 cases) and late-onset intracranial infection (63.6%, 7/11 cases). The differences between the 2 groups were statistically significant(all P<0.05). Laboratory tests of GBS sepsis showed that the early value of procalcitonin (PCT) increased, while the number of white blood cells, platelet decreased and C-reactive protein (CRP) increased relatively late.Chest X-ray examination showed 16 cases of pneumonia in children, 1 case of pulmonary hemorrhage, 1 case of bilateral pneumothorax. Head CT, B ultrasound, and magnetic resonance imaging discover 1 case of ventricular perivascular hemorrhage, 2 cases of intraventricular hemorrhage with ventricular dilatation and 1 case of subdural effusion.Drug sensitivity test showed that 30 cases of children were sensitive to Penicillin, Vancomycin among which 17 cases (56.66%) were cured, 4 cases (23.33%) were improved, 9 cases died, 6 cases died of abandoning treatment, and the total mortality was 30.00% (9/30 cases). The 6-month follow-up of 9 cases of purulent meningitis newborns showed that there were 2 cases of mild mental retardation and motor dysfunction, 1 case of mild ventricular dilatation with no progressive increase, and 6 cases with no significant sequelae. Conclusion The clinical manifestations of neonatal GBS sepsis are typical.Dynamically monitoring the changes of PCT, CRP, white blood cells and platelet helps to early identify GBS sepsis infection and use sensitive antibiotics to cure the newborns. Key words: Group B streptococcal; Infant, neonatal; Sepsis

Case 1: Term Newborn with Purple Rash at Birth

A male infant is born at 37 weeks and 6 days of gestation via planned cesarean delivery because of predicted macrosomia. The mother is a 23-year-old primigravida whose pregnancy had been complicated only by abnormal surveillance fetal ultrasonography findings concerning for fetal cardiac defect. Fetal echocardiography performed at approximately 32 weeks’ gestation revealed biventricular hypertrophy and a dysplastic tricuspid valve with mild-to-moderate insufficiency. The pregnancy had been otherwise unremarkable. The mother denies use of drugs, illicit or prescription, alcohol, and tobacco during the pregnancy. Prenatal testing had shown the following results: human immunodeficiency virus, nonreactive; hepatitis B surface antigen, negative; rapid plasma reagin, nonreactive; and rubella, immune. Birthweight and length are 4.33 kg (97th percentile) and 51 cm (69th percentile), respectively. He is admitted to the NICU with a “blueberry-muffin” rash. Examination on admission is significant for macroglossia, right preauricular pit, multiple erythematous and purple nodules, purpura, petechiae, ankyloglossia, and thick umbilical cord. Titers for cytomegalovirus (CMV), toxoplasma, and rubella and polymerase chain reaction testing for toxoplasma, parvovirus, CMV, and herpes simplex virus performed shortly after delivery are negative. Blood and cerebrospinal fluid cultures are also negative after 5 and 2 days, respectively. Abdominal ultrasonography excludes intra-abdominal tumors; however, the liver is at the upper end of normal at 6.1 cm. Head ultrasonography, computed tomography, and magnetic resonance imaging exclude calcifications as well as other abnormalities. Postnatal echocardiography reveals mild left ventricular dilation with borderline function, which resolves by 28 days after birth. Complete blood cell count at birth reveals the following: white blood cell count, 50×103 …

Pulmonary hypertension with warm hands

A 19-year-old woman of Moroccan descent presented with severe dyspnoea on exertion. She had difficulty walking stairs (New York Heart Association functional class 3) and accompanying symptoms included fatigue, palpitations...

Early diagnosis and outcome prediction of neonatal hypoxic-ischemic encephalopathy with color Doppler ultrasound.

To describe the ultrasound presentation of the brain and cerebral hemodynamics in neonates with hypoxic-ischemic encephalopathy (HIE) by comparison with control subjects. During June2012 to April2013, full term neonates who had clinical evidence of HIE were enrolled. Healthy newborns without HIE were used as a control group. Cerebral parenchyma, size of lateral ventricles and hemodynamic parameters of cerebral arteries were studied using two-dimensional duplex and color Doppler ultrasound. Neonates with moderate and severe HIE were followed-up with ultrasound for at least 3months. A total of 158consecutive neonates (82boys and 76girls), including 54 with mild HIE, 60 with moderate HIE and 44 with severe HIE were included. One hundred and twenty healthy newborns were randomly selected as a control group. Abnormal ultrasound findings of brain parenchyma were found in 25/54 (46.3%) neonates with mild HIE whereas they were found in 58/60 (96.7%) neonates with moderate HIE and 44/44 (100%) neonates with severe HIE. Almost all neonates with severe HIE had decreased cerebral artery blood flow velocity and increased resistance index of cerebral arteries. Of the 104neonates with moderate or severe HIE, follow-up ultrasound examination revealed cystic parenchymal lesions in 12/104 (11.5%), progressive ventricular dilatation and brain atrophy in 12/104 (11.5%), mild ventricular dilatation in 15/104 (14.4%) and leukoencephalomalacia in 2/104 (1.9%) neonates. Ultrasound features such as the size of lateral ventricles, altered brain parenchymal echogenicity and cerebral blood flow parameters are useful for the early diagnosis of HIE and help predict outcome.

Exposure to occupational air pollution and cardiac function in workers of the Esfahan Steel Industry, Iran.

Air pollution is recognized as an important risk factor for cardiovascular disease. We investigated association of exposure to occupational air pollution and cardiac function in the workers of the steel industry. Fifty male workers of the agglomeration and coke-making parts of the Esfahan Steel Company were randomly selected (n = 50). Workers in the administrative parts were studied as controls (n = 50). Those with known history of hypertension, dyslipidemia, or diabetes, and active smokers were not included. Data of age, body mass index, employment duration, blood pressure, fasting blood sugar, and lipid profile were gathered. Echocardiography was performed to evaluate cardiac function. Left ventricular ejection fraction was lower in workers of the agglomeration/coke-making parts than in controls (mean difference = 5 to 5.5%, P < 0.001). Mild right ventricular dilatation and grade I pulmonary hypertension were present in three (12%) workers of the coke-making part, but none of the controls (P = 0.010). According to these results, occupational air pollution exposure in workers of the steel industry is associated with left heart systolic dysfunction. Possible right heart insults due to air pollution exposure warrant further investigations.

Report a case of Ebstein's anomaly wich early diagnosis avoid iatrogenic acts

Introduction: Ebstein's anomaly is a rare malformation that corresponds to less than 1% of all congenital heart anomalies. It consist in the caudal displacement of the tricuspid valve with retrograde flow to the right atrium due to valvular insufficiency and is characterized by a variable spectrum of severity, being higher in the neonatal period. Objective: to report a case of Ebstein's anomaly wich early diagnosis avoid iatrogenic acts. Case report: a newborn at term, appropriate weight for gestational age, female, was born of natural childbirth, with Apgar score 8/9 from pregnancy without complications. At birth, not in need of resuscitation in the delivery room, but presented heart murmur and fall of saturation, being supported and then forwarded to the NICU. Not present hemodynamic instability. The chest x-ray showed increased cardiac area with increased right atrium. The Transthoracic Echocardiogram showed mild right ventricular dilatation and important of the right atrium, tricuspid valve dysplasia with low implantation of posterior leaflet of tricuspid insufficiency presence important to Doppler, being diagnosed with Ebstein's anomaly. Evolved with progressive improvement of the frame and saturation above 95% on room air to pulse oximetry. Patient follows in outpatient follow-up in use of inotropic and diuretic, remaining asymptomatic. Conclusion: the recognition of the gravity of the picture is relevant to the proper management in order to prevent iatrogenic ducts, which can lead to complications or permanent sequelae.

ECG In Evaluation for Pulmonary Thromboembolism- Occam's Razor or Hickam's Dictum?

The electrocardiogram (ECG) is a simple, universally available tool in emergency departments used in evaluation of acute chest pain. Among the differential diagnosis, Acute Pulmonary Thromboembolism (PTE) is important to recognize as the diagnosis, carries serious therapeutic and prognostic implications. A 28-year-old male presented to the emergency department with acute onset shortness of breath and chest pain for two days and two episodes of haemoptysis. He had sustained a road traffic accident with fracture of both bones of right leg one month back for which he had undergone open reduction and internal fixation. On examination, he was tachycardic (pulse rate-152/min) and tachypnoeic (respiratory rate-26/min) with normal blood pressure (116/78 mm of Hg) and oxygen saturation (96%) on breathing ambient air. His right lower limb was warm and swollen with tenderness along the femoral vein. The electrocardiogram (ECG) showed sinus tachycardia, right ventricular strain, right bundle branch block pattern and S1Q3T3 pattern [Table/Fig-1] suggestive of PTE. Compression ultrasound scan of right lower limb revealed echogenic contents in right femoro-popliteal veins indicative of Deep Vein Thrombosis (DVT). Computed tomographic angiogram of pulmonary arteries showed hypodense filling defect suggestive of thrombus involving the right main pulmonary artery [Table/Fig-2], extending into its descending branch. A 2-dimensional echocardiogram showed mild tricuspid regurgitation and mild right ventricular dilatation. Since the patient was haemodynamically stable, thrombolysis was not attempted. He was started on subcutaneous enoxaparin at 1 mg/kg/dose twice daily along with oral anticoagulation with warfarin. Patient improved and was discharged. On follow-up at one month, patient is asymptomatic for DVT or PTE and INR is in therapeutic range. [Table/Fig-1]: A 12-lead electrocardiogram (ECG) showing sinus tachycardia (heart rate- 150/min), right bundle branch block pattern (black arrows), T-inversion in aVF and typical S1Q3T3 pattern (red arrows) suggestive of pulmonary thromboembolism. [Table/Fig-2]: Axial computed tomographic angiogram section of pulmonary arteries showing hypodense filling defect (arrowhead) suggestive of thrombus involving the right main pulmonary artery. Common ECG abnormalities in PTE include sinus tachycardia and T wave inversions in precordial leads and a ventricular fibrillation (VF), right bundle branch block pattern, S1Q3T3 pattern, QR pattern in V1, QS pattern in precordial leads, ST-elevation in precordial leads and low voltage in limb leads. Classic changes like S1Q3T3 pattern tend to occur with more severe forms of PTE and correlate well with mortality [1]. S1Q3T3 pattern is a marker of acute cor-pulmonale and can occur with conditions like severe bronchospasm and pneumothorax [2]. Composite scores based on ECG in PTE can help in patient management. Using a 21-point scale, a score ≤3 in predicted normal right ventricular function [3]. QR in V1, ST-depression in V4-V6 and ST-elevation in lead III and V1 are associated with in-hospital mortality [1]. This case illustrates the classical ECG findings of PTE and the importance of an easily available, simple diagnostic test in diagnosing a life threatening condition. The classical signs in ECG can be used as a decision tool for further imaging and can also be used as an indicator for early referral of a patient especially in resource poor settings. To conclude, ECG in PTE can show a spectrum of changes from being normal to having multiple suggestive abnormalities. The ECG changes in PTE are not specific and similar changes may result from wide array of causes conferring to the principle of Hickam’s dictum. In general, the number of abnormalities on ECG correlates well with pulmonary artery pressures and the severity of PTE. Even though ECG can give a clue to the diagnosis of PTE, its actual role lies in prognostic assessment and hence can be used as a decision tool for further imaging and investigations especially in resource poor settings.

Brain MRI findings in aspartylglucosaminuria

The aim of this study was to identify characteristic 3.0 T brain MRI findings in patients with aspartylglucosaminuria (AGU), a rare lysosomal storage disorder. Previous AGU patient material imaged at 1.0 and 1.5 T was also re-evaluated. Twenty-five brain MRI examinations from 20 AGU patients were included in the study. Thirteen patients underwent a prospective 3.0 T MRI (5 male, 8 female, aged 9-45 years). Twelve examinations from nine patients (4 male, 5 female, aged 8-33 years) previously imaged at 1.0 or 1.5 T were re-evaluated. Two patients were included in both the prospective and the retrospective groups. Visual analysis of the T1- and T2-weighted images was performed by two radiologists. The previously reported signal intensity changes in T2-weighted images were visible at all field strengths, but they were more distinct at 3.0 T than at 1.0 or 1.5 T. These included signal intensity decrease in the thalami and especially in the pulvinar nuclei, periventricular signal intensity increase and juxtacortical high signal foci. Poor differentiation between gray and white matter was found in all patients. Some degree of cerebral and/or cerebellar atrophy and mild ventricular dilatation were found in nearly all patients. This study also disclosed various unspecific findings, including a higher than normal incidence of dilated perivascular spaces, arachnoid cysts, pineal cysts and mildly dilated cavum veli interpositi. This study revealed particular brain MRI findings in AGU, which can raise the suspicion of this rare disease in clinical practice.