Dilated Cardiomyopathy Due to Alimentary Iron Deficiency

Dilated cardiomyopathy (DCM) is a severe condition, characterised by left ventricular dilation and systolic dysfunction, necessitating heart transplantation when all other treatment options fail. This case report describes a 2-year-old girl initially presenting with oedema, listlessness, and severe iron deficiency anaemia. She was diagnosed with DCM. Extensive diagnostic workup ruled out other causes, leading to the suspicion of DCM due to alimentary iron deficiency. This was confirmed by the parents' report that the girl was fed almost exclusively with low-fat cow's milk. Prompt treatment, including packed red cell transfusion, iron supplementation, and heart failure medications (diuretics, ACE inhibitors, beta blockers, and aldosterone antagonists), resulted in significant improvement in cardiac function within days. This report demonstrates the potential risks of alimentary iron deficiency, the most common cause of microcytic hypochromic anaemia in young children, which might even result in the development of life-threatening cardiac dysfunction in extreme cases.

Myocarditis and sports in the young: data from a nationwide registry on myocarditis-"MYKKE-Sport"

Background

Myocarditis represents one of the most common causes of Sudden Cardiac Death in children. Myocardial involvement during a viral infection is believed to be higher as a consequence of intensive exertion. Recommendations for return to sports are based on cohort and case studies only. This study aims to investigate the relationship between physical activity and myocarditis in the young.

Patient

Every patient in the MYKKE registry fulfilling criteria for suspicion of myocarditis was sent a questionnaire regarding the physical activity before, during and after the onset of myocarditis.

Method

This study is a subproject within the MYKKE registry, a multicenter registry for children and adolescents with suspected myocarditis. The observation period for this analysis was 93 months (September 2013-June 2021). Anamnestic, cardiac magnetic resonance images, echocardiography, biopsy and laboratory records from every patient were retrieved from the MYKKE registry database.

Results

58 patients (mean age 14.6 years) were enrolled from 10 centers. Most patients participated in curricular physical activity and 36% in competitive sports before the onset of myocarditis. There was no significant difference of heart function at admission between the physically active and inactive subjects (ejection fraction of 51.8 ± 8.6% for the active group vs. 54.4 ± 7.7% for the inactive group). The recommendations regarding the return to sports varied widely and followed current guidelines in 45%. Most patients did not receive an exercise test before returning to sports.

Conclusion

Sports before the onset of myocarditis was not associated with a more severe outcome. There is still a discrepancy between current literature and actual recommendations given by health care providers. The fact that most participants did not receive an exercise test before being cleared for sports represents a serious omission.

Non-invasive pediatric cardiac imaging-current status and further perspectives

BACKGROUND

Non-invasive cardiac imaging has a growing role in diagnosis, differential diagnosis, therapy planning, and follow-up in children and adolescents with congenital and acquired cardiac diseases. This review is based on a systematic analysis of international peer-reviewed articles and additionally presents own clinical experiences. It provides an overview of technical advances, emerging clinical applications, and the aspect of artificial intelligence.

MAIN BODY

The main imaging modalities are echocardiography, CT, and MRI. For echocardiography, strain imaging allows a novel non-invasive assessment of tissue integrity, 3D imaging rapid holistic overviews of anatomy. Fast cardiac CT imaging new techniques-especially for coronary assessment as the main clinical indication-have significantly improved spatial and temporal resolution in adjunct with a major reduction in ionizing dose. For cardiac MRI, assessment of tissue integrity even without contrast agent application by mapping sequences is a major technical breakthrough. Fetal cardiac MRI is an emerging technology, which allows structural and functional assessment of fetal hearts including even 4D flow analyses. Last but not least, artificial intelligence will play an important role for improvements of data acquisition and interpretation in the near future.

CONCLUSION

Non-invasive cardiac imaging plays an integral part in the workup of children with heart disease. In recent years, its main application congenital heart disease has been widened for acquired cardiac diseases.

Left Ventricular Strain Analysis During Submaximal Semisupine Bicycle Exercise Stress Echocardiography in Childhood Cancer Survivors

Background

Childhood cancer survivors (CCSs) show relevant cardiac morbidity and mortality throughout life. Early detection is key for optimal support of patients at risk. The aim of this study was to evaluate 2‐dimensional speckle‐tracking echocardiography strain analysis during semisupine exercise stress in CCSs for detection of subclinical left ventricular dysfunction after cancer treatment.

Methods and Results

Seventy‐seven CCSs ≥1‐year postchemotherapy were prospectively examined at rest, low, and submaximal stress level and compared with a cohort of healthy adolescents and young adults (n=50). Global longitudinal strain (GLS), short axis circumferential strain, and corresponding strain rates were analyzed using vendor‐independent software. CCSs at median 7.8 years postchemotherapy showed comparable left ventricular GLS, circumferential strain, and strain rate values at all stress stages to healthy controls. Yet, prevalence of abnormal GLS (defined as <2 SD of controls reference) in CCSs was 1.3% at rest, 2.7% at low, and 8.6% at submaximal stress. In CCSs, relative change of circumferential strain from rest to submaximal stress was lower than in healthy controls, median 16.9 (interquartile range [IQR], 3.4; 28.8) % versus 23.3 (IQR, 11.3; 33.3) %, P=0.03, most apparent in the subgroups of CCSs after high‐dose anthracycline treatment and cancer diagnosis before the age of 5 years.

Conclusions

In this prospective 2‐dimensional speckle tracking echocardiography strain study, prevalence of abnormal left ventricular GLS increased with stress level reflecting impaired cardiac adaptation to exercise stress in some CCSs. However, relatively early after last chemotherapy, this did not result in significant differences of mean GLS‐, circumferential strain‐, and strain rate values between CCSs and controls at any stress level.

Clinical characteristics and outcome of biopsy-proven myocarditis in children - Results of the German prospective multicentre registry "MYKKE"

BACKGROUND

Heart failure (HF) due to myocarditis might not respond in the same way to standard therapy as HF due to other aetiologies. The aim of this study was to investigate the value of endomyocardial biopsies (EMB) for clinical decision-making and its relation to the outcome of paediatric patients with myocarditis.

METHODS

Clinical and EMB data of children with myocarditis collected for the MYKKE-registry between 2013 and 2020 from 23 centres were analysed. EMB studies included histology, immunohistology, and molecular pathology. The occurrence of major adverse cardiac events (MACE) including mechanical circulatory support (MCS), heart transplantation, and/or death was defined as a combined endpoint.

RESULTS

Myocarditis was diagnosed in 209/260 patients: 64% healing/chronic lymphocytic myocarditis, 23% acute lymphocytic myocarditis (AM), 14% healed myocarditis, no giant cell myocarditis. The median age was 12.8 (1.4-15.9) years. Time from symptom-onset to EMB was 11.0 (4.0-29.0) days. Children with AM and high amounts of mononuclear cell infiltrates were significantly younger with signs of HF compared to those with healing/chronic or healed myocarditis. Myocardial viral DNA/RNA detection had no significant effect on outcome. The worst event-free survival was seen in patients with healing/chronic myocarditis (24%), followed by acute (31%) and healed myocarditis (58%, p = 0.294). A weaning rate of 64% from MCS was found in AM.

CONCLUSIONS

EMB provides important information on the type and stage of myocardial inflammation and supports further decision-making. Children with fulminant clinical presentation, high amounts of mononuclear cell infiltrates or healing/chronic inflammation and young age have the highest risk for MACE.

Cardiac catheterization in pediatric pulmonary hypertension: a systematic and practical approach

Significant progress in the understanding of the etiology, epidemiology, pathobiology and prognosis of pulmonary hypertension (PH) has been made over the last years. Especially in the pediatric patient population the etiology of PH is very heterogeneous. Nevertheless, the most recent change of the definition of PH to a mean pulmonary artery pressure (mPAP) >20 mmHg has been accepted by pediatricians for uniformity and concordance with adult physicians. Based on the diverse underlying medical conditions leading to PH, a comprehensive and systematic approach for diagnosis and treatment is mandatory. Cardiac catheterization remains the gold standard for invasive assessment and acute vasoreactivity testing (AVT) additionally providing detailed information about nature of PH. In most patients repeat cardiac catheterization may be helpful for evaluation of response to targeted PH treatment, risk stratification and indication for lung transplantation. However, the information and results taken from cardiac catheterization should be interpreted by experienced investigators only who are familiar with confounding factors that may influence the results. Here we provide an overview of current recommendations for invasive hemodynamic evaluation in pediatric PH. We point out different patient scenarios and provide a structured approach for AVT and response interpretation.

Moyamoya disease associated with pediatric pulmonary hypertension-a case report

Moyamoya disease (MD) is a rare vaso-occlusive disorder that primarily affects intracranial cerebral arteries. The involvement of extracranial vessels is unusual. However, there are previous reports suggesting MD to be a systemic disorder, causing disease manifestations in vessels of other parts of the body. We report the case of a female patient with MD and multiple episodes of ischemic strokes followed by bypass surgery of cerebral arteries during infancy. Due to corresponding ischemic lesions the girl showed global retardation of psychomotor development and central right sided movement disorder. At the age of 10 years the girl was admitted to our hospital with recurrent syncope. While cranial MRI excluded any newly added ischemic lesions, electrocardiography revealed evidence of right ventricular hypertrophy, and subsequent echocardiography then indicated pulmonary hypertension, which was confirmed by cardiac catheterization. Despite an upfront combination pulmonary vasodilating therapy, the pulmonary vascular disease appeared to be progressive. Genetic analysis showed heterozygous c.12341C>T mutation in the RNF213 gene. This case presentation demonstrates that pulmonary arterial hypertension is a rare comorbidity in patients with MD, especially in patients with genetic predictors such as the RNF213 mutation. Thus, regular echocardiographic screening for early signs of pulmonary arterial hypertension in patients with MD should be part of regular clinical work-up. Early detection and treatment of pulmonary arterial hypertension in MD might help to improve the long-term outcome in the individual patient.

Spontaneous Closure of Perimembranous Ventricular Septal Defects: A Janus-Faced Condition

•Large perimembranous VSDs can occasionally close spontaneously by a septal aneurysm. •Complications of aneurysmatic VSD closure include RVOT obstruction. •The use of multimodal imaging allows accurate diagnosis of RVOT obstruction. •RVOT obstruction due to septal aneurysm is preferably treated by surgical excision. •Patients with aneurysmatic closure of perimembranous VSD need life-long observation.

Neue hämodynamische Definition der pulmonalen Hypertonie

Eine pathologische Druckerhöhung im pulmonalen Gefäßsystem (pulmonale Hypertonie, PH) wurde bisher definiert durch einen invasiv gemessenen mittleren pulmonalarteriellen Druck (mPAP) ≥25 mm Hg in Ruhe. Auf dem 6th World Symposium on Pulmonary Hypertension (WSPH) in Nizza 2018 wurde eine neue Definition der PH vorgeschlagen, die die Senkung der Obergrenze des normalen mPAP von 24 auf 20 mm Hg beinhaltet.

Obwohl keine Evidenz aus pädiatrischen Studien hierfür vorliegt, wurde diese neue PH-Definition (mPAP >20 mm Hg) aus Gründen der Einheitlichkeit auch von der pädiatrischen „Task Force“ des WSPH 2018 übernommen.

Die vorliegende Stellungnahme der Arbeitsgemeinschaft Pulmonale Hypertonie (AGPH) der Deutschen Gesellschaft für Pädiatrische Kardiologie und angeborene Herzfehler e. V. (DGPK) erläutert die zugrunde liegende Rationale und mögliche Konsequenzen dieser Definitionsänderung. Insbesondere stellt sie klar, dass diese Änderung der Definition aktuell keinen Einfluss auf die Verschreibung von Medikamenten zur gezielten spezifischen Therapie der pulmonalarteriellen Hypertonie hat.

Heart Rate Response During Treadmill Exercise Test in Children and Adolescents With Congenital Heart Disease

Background: Impaired exercise capacity is a common feature of congenital heart disease (CHD). In adults with CHD, it has been shown that impaired heart rate response during exercise may contribute to exercise limitation. Systematic data in children and adolescents on this topic is limited. We therefore purposed to assess heart rate response during treadmill exercise testing in children and adolescents with CHD compared to healthy controls. Methods: One hundred and sixty three children and adolescents (103 with CHD, median age 15 years and 60 age-matched controls) performed cardiopulmonary exercise testing and were included in this study. Beyond peak oxygen consumption, increase in heart rate from resting level to peak exercise (heart rate reserve) and decrease of heart rate after peak exercise (heart rate recovery) were measured. Chronotropic index was defined as percentage of age predicted maximal heart rate reserve. According to data from adults on bicycle exercise, chronotropic incompetence was assumed for chronotropic index below 0.8. Results: While resting heart rate was similar between both groups, peak heart rate, heart rate reserve as well as chronotropic index were lower in the CHD group than in controls. Chronotropic index was lowest in patients with single ventricle hemodynamics and correlated with peak oxygen consumption. Heart rate recovery was impaired in the CHD group 1 and 2 min after peak exercise compared to controls and correlated with peak oxygen consumption. Chronotropic index below 0.8 was a relatively frequent finding even in the control group suggesting that the threshold of 0.8 appears inadequate for the identification of chronotropic incompetence using treadmill exercise testing in children. After normalizing to the 2.5th chronotropic index percentile of the control group we obtained a chronotropic incompetence threshold of 0.69. Conclusion: As an adjunct to measurement of peak oxygen consumption, heart rate response to exercise appears to be a physiologically important diagnostic parameter in children and adolescents with CHD. However, interpretation of heart rate response needs to consider specific age characteristics and the mode of exercise test. Our data may help future studies on chronotropic incompetence using treadmill ergometer protocols in children and adolescents.

Impact of the Right Ventricular Sokolow-Lyon Index in Children with Idiopathic Pulmonary Arterial Hypertension

Right ventricular (RV) hypertrophy is regarded as the adaptation on chronic RV pressure load in pulmonary hypertension. As the RV Sokolow-Lyon index (RVSLI) is an electrocardiographic marker of RV hypertrophy, we hypothesized that RVSLI might be able to reflect RV pressure load. Therefore, the purpose of this study was to characterize the diagnostic impact of the RVSLI in children with idiopathic pulmonary arterial hypertension (IPAH) in order to assess disease severity and to evaluate its value for the prediction of worse outcome. Forty-two children (aged 3-17 years) with IPAH were included in this retrospective study. The follow-up after baseline examination was 59 ± 17 months. Receiver-operating characteristic (ROC) curves and Kaplan-Meier analysis were used to discriminate a cut-off value of RVSLI and to assess its predictive value regarding morbidity and mortality. In 12/42 patients (29%) severe cardiovascular events (defined as death, lung transplantation, or Potts shunt) were observed (time to event 20 ± 22 months). Patients with an event showed higher RVSLI values (3.6 ± 1.2 mV vs. 2.6 ± 1.6 mV; p < 0.05). ROC analysis discriminated an RVSLI of 2.1 as the best cut-off value (area under the ROC curve: 0.79, sensitivity: 0.91, specificity: 0.70, p < 0.05) to detect patients with high-risk PAH (mPAP/mSAP ratio > 0.75). Relative risk for a severe event with an index > 2.1 mV was 1.76 (95% CI 1.21-3.20). Relative risk for death with RVSLI > 2.1 mV was 2.01 (95% CI 1.61-4.80). Our study demonstrates a strong relationship between RVSLI and disease severity in children with IPAH. An RVSLI > 2.1 mV at the time of first diagnosis is a predictor for patients at risk for cardiac events. As an adjunct to the usual diagnostic assessment this parameter may therefore contribute to the initial prognostic estimation.

Quantitative, Phenotypical, and Functional Characterization of Cellular Immunity in Children and Adolescents With Down Syndrome

Background

Infections and autoimmune disorders are more frequent in Down syndrome, suggesting abnormality of adaptive immunity. Although the role of B cells and antibodies is well characterized, knowledge regarding T cells is limited.

Methods

Lymphocyte subpopulations of 40 children and adolescents with Down syndrome and 51 controls were quantified, and phenotype and functionality of antigen-specific effector T cells were analyzed with flow cytometry after polyclonal and pathogen-specific stimulation (with varicella-zoster virus [VZV] and cytomegalovirus [CMV]). Results were correlated with immunoglobulin (Ig) G responses.

Results

Apart from general alterations in the percentage of lymphocytes, regulatory T cells, and T-helper 1 and 17 cells, all major T-cell subpopulations showed higher expression of the inhibitory receptor PD-1. Polyclonally stimulated effector CD4+ T-cell frequencies were significantly higher in subjects with Down syndrome, whereas their inhibitory receptor expression (programmed cell death 1 [PD-1] and cytotoxic T-lymphocyte antigen 4 [CTLA-4]) was similar to that of controls and cytokine expression profiles were only marginally altered. Pathogen-specific immunity showed age-appropriate levels of endemic infection, with correlation of CMV-specific cellular and humoral immunity in all subjects. Among VZV IgG-positive individuals, a higher percentage of VZV-specific T-cell-positive subjects was seen in those with Down syndrome.

Conclusions

Despite alterations in lymphocyte subpopulations, individuals with Down syndrome can mount effector T-cell responses with similar phenotype and functionality as controls but may require higher effector T-cell frequencies to ensure pathogen control.

Toward evidence-based diagnosis of myocarditis in children and adolescents: Rationale, design, and first baseline data of MYKKE, a multicenter registry and study platform

The aim of this registry is to provide data on age-related clinical features of suspected myocarditis and to create a study platform allowing for deriving diagnostic criteria and, at a later stage, testing therapeutic interventions in patients with myocarditis.

STUDY DESIGN AND RESULTS

After an initial 6-month pilot phase, MYKKE was opened in June 2014 as a prospective multicenter registry for patients from pediatric heart centers, university hospitals, and community hospitals with pediatric cardiology wards in Germany. Inclusion criteria consisted of age<18 years and hospitalization for suspected myocarditis as leading diagnosis at the discretion of the treating physician. By December 31, 2015, fifteen centers across Germany were actively participating and had enrolled 149 patients. Baseline data reveal 2 age peaks (<2 years, >12 years), show higher proportions of males, and document a high prevalence of severe disease courses in pediatric patients with suspected myocarditis. Severe clinical courses and early adverse events were more prevalent in younger patients and were related to severely impaired leftventricular ejection fraction at initial presentation.

SUMMARY

MYKKE represents a multicenter registry and research platform for children and adolescents with suspected myocarditis that achieve steady recruitment and generate a wide range of real-world data on clinical course, diagnostic workup, and treatment of this group of patients. The baseline data reveal the presence of 2 age peaks and provide important insights into the severity of disease in children with suspected myocarditis. In the future, MYKKE might facilitate interventional substudies by providing an established collaborating network using common diagnostic approaches.

Home Exercise Training in Children and Adolescents with Pulmonary Arterial Hypertension: A Pilot Study

Pulmonary arterial hypertension (PAH) is often associated with impaired exercise capacity. It has been shown that supervised training can improve exercise capacity in adult patients with PAH. The objective of this prospective study was to assess the feasibility of a home exercise training program in children with PAH. Nine children and adolescents (mean age 15.2 ± 3.8 years) with low-risk PAH (defined as mean pulmonary to systemic arterial pressure ratio <0.75; WHO functional class I and II) performed home-based exercise training for 16 weeks. Cardiopulmonary exercise testing and health-related quality of life was evaluated before and after 16 weeks of training. The amount of training at home and patients' well-being was supervised by periodical phone calls and online-questionnaires. Home exercise training was well tolerated in all patients, and no adverse events occurred. After 16 weeks of training, patients significantly improved their exercise capacity [treadmill running distance increased from 589.5 ± 153.9 to 747.9 ± 209.2 m (p = 0.036)]. Oxygen consumption at the anaerobic threshold increased from 1307.8 (±417) to 1406.4 (±418) ml (p = 0.028). Chronotropic index improved from 0.77 ± 0.12 to 0.82 ± 0.11 (p = 0.004) and was slightly related to the increase in running distance (r = 0.62; p = 0.07). Home exercise training is feasible in children and adolescents with low-risk PAH, and the preliminary results of this pilot study indicate beneficial effects. The observed increase in exercise capacity was accompanied by an improved chronotropic competence and increased oxygen consumption at the anaerobic threshold. Future research is needed to investigate the safety and efficacy of home exercise training in a larger population of children with PAH including also patients in WHO functional class III or IV.

Executive summary. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK

: The European Paediatric Pulmonary Vascular Disease (PVD) Network is a registered, non-profit organisation that strives to define and develop effective, innovative diagnostic methods and treatment options in all forms of paediatric pulmonary hypertensive vascular disease, including specific forms such as pulmonary arterial hypertension (PAH)-congenital heart disease, pulmonary hypertension (PH) associated with bronchopulmonary dysplasia, persistent PH of the newborn, and related cardiac dysfunction.

METHODS

The writing group members conducted searches of the PubMed/MEDLINE bibliographic database (1990-2015) and held five face-to-face meetings with votings. Clinical trials, guidelines, and reviews limited to paediatric data were searched using the terms 'pulmonary hypertensioń' and 5-10 other keywords, as outlined in the other nine articles of this special issue. Class of recommendation (COR) and level of evidence (LOE) were assigned based on European Society of Cardiology/American Heart Association definitions and on paediatric data only, or on adult studies that included >10% children.

RESULTS

A total of 9 original consensus articles with graded recommendations (COR/LOE) were developed, and are summarised here. The topics included diagnosis/monitoring, genetics/biomarker, cardiac catheterisation, echocardiography, cardiac magnetic resonance/chest CT, associated forms of PH, intensive care unit/ventricular assist device/lung transplantation, and treatment of paediatric PAH.

CONCLUSIONS

The multipaper expert consensus statement of the European Paediatric PVD Network provides a specific, comprehensive, detailed but practical framework for the optimal clinical care of children with PH.

Response of ammonium removal to growth and transpiration of Juncus effusus during the treatment of artificial sewage in laboratory-scale wetlands

The correlation between nitrogen removal and the role of the plants in the rhizosphere of constructed wetlands are the subject of continuous discussion, but knowledge is still insufficient. Since the influence of plant growth and physiological activity on ammonium removal has not been well characterized in constructed wetlands so far, this aspect is investigated in more detail in model wetlands under defined laboratory conditions using Juncus effusus for treating an artificial sewage. Growth and physiological activity, such as plant transpiration, have been found to correlate with both the efficiency of ammonium removal within the rhizosphere of J. effusus and the methane formation. The uptake of ammonium by growing plant stocks is within in a range of 45.5%, but under conditions of plant growth stagnation, a further nearly complete removal of the ammonium load points to the likely existence of additional nitrogen removal processes. In this way, a linear correlation between the ammonium concentration inside the rhizosphere and the transpiration of the plant stocks implies that an influence of plant physiological activity on the efficiency of N-removal exists. Furthermore, a linear correlation between methane concentration and plant transpiration has been estimated. The findings indicate a fast response of redox processes to plant activities. Accordingly, not only the influence of plant transpiration activity on the plant-internal convective gas transport, the radial oxygen loss by the plant roots and the efficiency of nitrification within the rhizosphere, but also the nitrogen gas released by phytovolatilization are discussed. The results achieved by using an unplanted control system are different in principle and characterized by a low efficiency of ammonium removal and a high methane enrichment of up to a maximum of 72.7% saturation.

Adaptation of a constructed wetland to simultaneous treatment of monochlorobenzene and perchloroethene

Mixed groundwater contaminations by chlorinated volatile organic compounds (VOC) cause environmental hazards if contaminated groundwater discharges into surface waters and river floodplains. Constructed wetlands (CW) or engineered natural wetlands provide a promising technology for the protection of sensitive water bodies. We adapted a constructed wetland able to treat monochlorobenzene (MCB) contaminated groundwater to a mixture of MCB and tetrachloroethene (PCE), representing low and high chlorinated model VOC. Simultaneous treatment of both compounds was efficient after an adaptation time of 2 1/2 years. Removal of MCB was temporarily impaired by PCE addition, but after adaptation a MCB concentration decrease of up to 64% (55.3 micromol L(-1)) was observed. Oxygen availability in the rhizosphere was relatively low, leading to sub-optimal MCB elimination but providing also appropriate conditions for PCE dechlorination. PCE and metabolites concentration patterns indicated a very slow system adaptation. However, under steady state conditions complete removal of PCE inflow concentrations of 10-15 micromol L(-1) was achieved with negligible concentrations of chlorinated metabolites in the outflow. Recovery of total dechlorination metabolite loads corresponding to 100%, and ethene loads corresponding to 30% of the PCE inflow load provided evidence for complete reductive dechlorination, corroborated by the detection of Dehalococcoides sp.

Rhamnolipid biosurfactants decrease the toxicity of chlorinated phenols to Pseudomonas putida DOT-T1E

AIMS

To investigate the effect of a mixture of rhamnolipid R1 and R2 biosurfactants produced by a Pseudomonas aeruginosa strain on the toxicity of phenol and chlorophenols to Pseudomonas putida DOT-T1E.

METHODS AND RESULTS

Toxicity was quantified by the effective concentration 50% (EC50), that is the concentration that causes a 50% inhibition of bacterial growth. The presence of 300 mg l(-1) rhamnolipids, that is at about twice their critical micelle concentration (CMC), increased the EC50 of phenol, 4-chlorophenol, 2,4-dichlorophenol and 2,4,5-trichlorophenol by about 12, 19, 32 and 40%, respectively, and consequently reduced the bioavailability and the freely dissolved concentration of the toxic phenolic compounds. The reduction was related to the phenols' octanol-water partition coefficients (K(ow)).

CONCLUSIONS

The reduction in toxicity of the phenols can be explained by a combination of toxin accumulation in biosurfactant micelles and hydrophobic interactions of the phenols with rhamnolipid-based dissolved organic carbon.

SIGNIFICANCE AND IMPACT OF THE STUDY

Results provide evidence that next to the effect of the micelle formation also hydrophobic interactions with rhamnolipid-based dissolved organic carbon affects the bioavailability of the phenols. Quantifying the effect of biosurfactants on the toxicity of hydrophobic compounds such as phenols thus appears to be a useful approach to assess their bioavailable equilibrium concentration.

Function of Contegra valved grafts after unifocalization

BACKGROUND

Can Contegra grafts withstand high pressure?

METHODS

The function of Contegra grafts implanted after unifocalization of major aortopulmonary collateral arteries (MAPCAs) in 10 patients was evaluated. Median age at repair was 194 days and two conduit sizes were used: 12 mm (n = 8) and 14 mm (n = 2). Echocardiography and heart catheterization findings were reviewed.

RESULTS

Two patients died: one early after repair, one late. Death was not graft related. The median duration of observation for survivors was 31 (range 4 - 42) months. The postoperative right ventricular/left ventricular pressure ratio was greater than 75 % in 9 patients. High pressures persisted in 6 survivors. Seven patients underwent interventional dilatation/stenting of pulmonary arteries on 19 occasions. No obstruction was detected in the conduit. Graft valve regurgitation increased in 5 patients, but never exceeded grade 2 (n = 4). Freedom from reoperation for conduit dysfunction/failure was 100 % at month 42.

CONCLUSION

At mid-term follow-up, the Contegra grafts withstood high pressure without significant dysfunction or aneurysmal dilatation requiring surgery. Contegra appears to be an acceptable alternative to the aortic homograft for use after unifocalization of MAPCAs in infancy.

Physiological responses of Juncus effusus (Rush) to chromium and relevance for wastewater treatment in constructed wetlands

Constructed wetlands are increasingly applied for industrial wastewater treatment. However, current knowledge of the stress responses of helophytes to selected toxicants such as dichromate is limited. The goal of the experiments presented here was to characterize the physiological response of Juncus effusus to different concentrations of dichromate dependent upon the growth and constitution of the plants. The growth parameters, shoot length, and dry weight already were strongly affected at low dichromate concentrations of approximately 34 microM. Concentrations of 340 microM impaired chlorophyll fluorescence and a decrease in chlorophyll a started at concentrations higher than 170 microM dichromate. The concentrations of chlorophyll b and carotenoids also were influenced negatively. Thus, the reduction of the pigment content started before any obvious influence on the chlorophyll fluorescence. The highest concentration of dichromate, which caused no permanent inhibition of growth and photosynthesis, was found to be 17 microM K2Cr2O7. In principle, J. effusus is suitable for constructed wetlands to treat chromium-containing wastewater. Because the stress resistance of J. effusus is limited, the maximum concentration of dichromate in the treated wastewater should not exceed 34 microM. The growth parameters, shoot length, and dry weight were sensitive to much lower dichromate concentrations and did react more quickly than the biochemistry-related parameters chlorophyll fluorescence and pigment concentration. Therefore, the example of Juncus effusus shows that the use of only biochemical parameters to define concentration limits for the treatment of dichromate-containing wastewater can lead to incorrect conclusions and result in disturbed long-term operation of the system.

Anaerobic co-reduction of chromate and nitrate by bacterial cultures of Staphylococcus epidermidis L-02

Industrial wastewater is often polluted by Cr(VI) compounds, presenting a serious environmental problem. This study addresses the removal of toxic, mutagenic Cr(VI) by means of microbial reduction to Cr(III), which can then be precipitated as oxides or hydroxides and extracted from the aquatic system. A strain of Staphylococcus epidermidis L-02 was isolated from a bacterial consortium used for the remediation of a chromate-contaminated constructed wetland system. This strain reduced Cr(VI) by using pyruvate as an electron donor under anaerobic conditions. The aims of the present study were to investigate the specific rate of Cr(VI) reduction by the strain L-02, the effects of chromate and nitrate (available as electron acceptors) on the strain, and the interference of chromate and nitrate reduction processes. The presence of Cr(VI) decreased the growth rate of the bacterium. Chromate and nitrate reduction did not occur under sterile conditions but was observed during tests with the strain L-02. The presence of nitrate increased both the specific Cr(VI) reduction rate and the cell number. Under denitrifying conditions, Cr(VI) reduction was not inhibited by nitrite, which was produced during nitrate reduction. The average specific rate of chromate reduction reached 4.4 micromol Cr 10(10 )cells(-1 )h(-1), but was only 2.0 micromol Cr 10(10 )cells(-1 )h(-1) at 20 degrees C. The maximum specific rate was as high as 8.8-9.8 micromol Cr 10(10 )cells(-1 )h(-1). The role of nitrate in chromate reduction is discussed.

Unusual electrocardiogram findings in a preterm infant after fetal tachycardia with hydrops fetalis treated with flecainide

Fetal tachycardia and signs of hydrops fetalis were diagnosed at 29 weeks of gestation. The heart rate normalized by combined treatment with digoxin and flecainide and was followed by improvement of the hydrops. Premature labor led to delivery at 33 weeks of gestation. The newborn infant showed mild respiratory distress and was in a hemodynamically stable condition. Marked QT segment anomalies on the electrocardiogram during the first postnatal days resolved completely within 3 weeks. They were unlikely to be attributable to myocarditis or myocardial infarction. We speculate that these anomalies were caused by the maternal flecainide therapy.

Rotation of the gut: fact or fantasy?

Clinicians, as well as embryologists, believe that normally a process of rotation of the midgut takes place that can be hampered at any stage resulting in the different types of "malrotations." However, a "malrotated" gut has never been observed in normal embryos. Therefore all theories on the normal and abnormal development of the gut are still highly hypothetical. In an attempt to elucidate more clearly which events occur during the development of the gut, the authors studied its embryology in 58 normal rat embryos between the 13th and 20th day of gestation using scanning electron microscopy. In 13 day old rat embryos, the midgut has already formed a loop. It can be subdivided into three parts: the central part with its connections to the stomach and leading to the straight part, with the colorectum on the left and the "small bowel" on the right, and the tip of the loop inside the umbilical cord. These three parts show no signs of developmental synchronization. Each part develops according to its own developmental blueprint: the duodenal and umbilical parts of the midgut show much developmental activity, whereas gross changes of the straight part of the midgut are not seen. This finding is surprising because a process of rotation, if occurring, should result in notable morphological changes especially in this region. Furthermore, the coecum never achieved a position in the upper left abdomen, as is often outlined in schematic drawings. After the return of the bowel into the abdominal cavity, the coecum lies exclusively on the right side of the midline close to the ventral abdominal wall.(ABSTRACT TRUNCATED AT 250 WORDS)

Optical properties of the atmosphere: calculated variability and application to satellite remote sensing of phytoplankton

The radiative transfer equation is solved by the method of successive orders of scattering for several different model atmospheres, taking into account the realistic variability of scattering and absorption. A windruffled ocean surface with whitecaps and with different phytoplankton content is also taken into account. The variation of the ocean-leaving radiance when traveling through the atmosphere is investigated. Calculations are performed at five wavelengths from 0.443 to 0.750 microm, according to the channels of the Coastal Zone Color Scanner (CZCS) on board the Nimbus 7 satellite. The radiance reaching the satellite amounts to only 5% of the radiation that penetrated the ocean, and consequently 95% of the radiation is scattered in the atmosphere or reflected at the ocean surface. Radiance variation at the satellite due to phytoplankton variations lies on the order of 1%, while the radiance variation due to the realistic spread of the optically relevant atmospheric and oceanic constituents is considerably higher. The variability of the atmospheric turbidity already causes changes up to 10% in the radiance at the satellite.