[Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]

BACKGROUND

Autopsies are a valuable tool for understanding disease, including COVID-19.

MATERIALS AND METHODS

The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs.

RESULTS

The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy.

CONCLUSIONS

Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.

Identification of the flotillin-1/2 heterocomplex as a target of autoantibodies in bona fide multiple sclerosis

BACKGROUND

Autoantibodies, in particular those against aquaporin-4 and myelin-oligodendrocyte glycoprotein (MOG), aid as biomarkers in the differential diagnosis of demyelination. Here, we report on discovery of autoantibodies against flotillin in patients with multiple sclerosis (MS).

METHODS

The target antigen was identified by histo-immunoprecipitation using the patients' sera and cryosections of rat or pig cerebellum combined with mass spectrometrical analysis. Correct identification was ascertained by indirect immunofluorescence and neutralization tests using the target antigens recombinantly expressed in HEK293 cells.

RESULTS

Serum and CSF of the index patient produced a fine-granular IgG indirect immunofluorescence staining of the hippocampal and cerebellar molecular layers. Flotillin-1 and flotillin-2 were identified as target autoantigens. They also reacted with recombinant human flotillin-1/2 co-expressed in HEK293 cells, but not with the individual flotillins in fixed- and live-cell assays. Moreover, neutralization using flotillin-1/2, but not the single flotillins, abolished the tissue reactivity of patient serum. Screening of 521 patients, for whom anti-aquaporin-4 testing was requested and negative, revealed 8 additional patients with anti-flotillin-1/2 autoantibodies. All eight were negative for anti-MOG. Six patients ex post fulfilled the revised McDonald criteria for MS. Vice versa, screening of 538 MS sera revealed anti-flotillin-1/2 autoantibodies in eight patients. The autoantibodies were not found in a cohort of 67 patients with other neural autoantibody-associated syndromes and in 444 healthy blood donors.

CONCLUSIONS

Autoantibodies against the flotillin-1/2 heterocomplex, a peripheral membrane protein that is involved in axon outgrowth and regeneration of the optic nerve, are present in 1-2% of patients with bona fide MS.

[Recurrent episodes of headache]

Mollaret's meningitis is a recurrent meningitis, usually caused by Herpes simplex virus type 2. Symptoms are typical for meningitis, but other causes for recurrent and chronic meningitis have to be excluded in the cerebrospinal fluid. Usually Mollaret's meningitis is a benign form of meningitis without sequelae. There are no evidence-based data about therapy because of few reported cases.

Polyspecific, antiviral immune response distinguishes multiple sclerosis and neuromyelitis optica

BACKGROUND

A polyspecific, intrathecal humoral immune response against neurotropic viruses such as measles, rubella and varicella zoster virus (MRZ reaction, MRZR) is present in 80-100% of patients with multiple sclerosis (MS), but has not to date been evaluated in patients with neuromyelitis optica (NMO).

AIMS

To evaluate whether MRZR distinguishes NMO and MS.

METHODS

20 patients with NMO and 42 with MS were included. The intrathecal synthesis of antibodies against measles, rubella and varicella zoster virus was detected by calculation of the respective antibody indices (AI).

RESULTS

A positive MRZ reaction, as defined by a combination of at least two positive AIs, was found in 37/42 MS, but in only 1/20 NMO patients (p<0.0001). Median AI values differed significantly between the groups (p<0.0005).

CONCLUSIONS

The polyspecific antiviral humoral immune response characteristic for MS is widely missing in NMO, irrespective of the NMO-IgG status of the patients. Our findings further strengthen the case for NMO being pathologically distinct from MS.

Interstitial nephritis and high titers of PR3-ANCA: an unusual manifestation of ANCA-associated disease

We present the case of a 75-year-old female with weight loss, anemia, systemic signs of inflammation, mild renal insufficiency, microscopic hematuria, mixed glomerular and tubular proteinuria, and high titers of PR3-ANCA. Renal biopsy demonstrated interstitial nephritis with some sclerosed but otherwise normal glomeruli. Extensive work-up showed no signs of granulomatous inflammation or other vasculitic organ involvement. We presumed this to be a rare renal manifestation of ANCA-associated disease with the presence of sclerosed glomeruli suggesting a previous history of glomerular involvement. In view of the absence of active vasculitic or granulomatous disease, treatment was limited to low-dose corticosteroids with good response.

Parvibaculum lavamentivorans converts linear alkylbenzenesulphonate surfactant to sulphophenylcarboxylates, alpha,beta-unsaturated sulphophenylcarboxylates and sulphophenyldicarboxylates, which are degraded in communities

AIMS

The aims were to test whether Parvibaculum lavamentivoransT degraded commercial linear alkylbenzenesulphonate (LAS) surfactant via omega-oxygenation and beta-oxidation to sulphophenylcarboxylates (SPCs), whether the organism was widespread and reisolable, and whether the degradative community used the 4-sulphocatechol 1,2-dioxygenase to cleave the aromatic ring from LAS.

METHODS AND RESULTS

Heterotrophic P. lavamentivoransT converted LAS (side chain length C10-C13) to SPCs (C4-C13), alpha,beta-unsaturated SPCs (C4-C13) and sulphophenyldicarboxylates (SPdCs) (at least C8-C12). Identifications came from high performance liquid chromatography (HPLC) separation, an electrospray interface and mass spectrometry. No evidence for other paths was found. The degradation of LAS in trickling filters inoculated with environmental samples always showed transient SPC intermediates (HPLC) and the presence of the P. lavamentivorans morphotype in the community. One new isolate was obtained. A community able to mineralize LAS contained 4-sulphocatechol-1,2-dioxygenase at high specific activity.

CONCLUSIONS

Parvibaculum lavamentivoransT degrades commercial LAS via omega-oxygenation, oxidation and chain shortening through beta-oxidation to yield a wide range of SPCs. The latter are degraded in bacterial communities which contain organisms like P. lavamentivorans, and which utilize sulphocatechol dioxygenase for ring cleavage.

SIGNIFICANCE AND IMPACT OF THE STUDY

There is one widespread pathway to degrade LAS. Any traces of LAS and larger amounts of SPCs in the effluent from sewage works are exposed to degradative organisms in acclimated and pristine environments. These degradative reactions can now be studied in pure cultures.

Recalcitrance of poly(vinylpyrrolidone): evidence through matrix-assisted laser desorption-ionization time-of-flight mass spectrometry

The aerobic biodegradability of an extensively used synthetic polymer was monitored the first time on a laboratory-scale fixed-bed bioreactor (FBBR) applying matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS). Polymeric poly(vinylpyrrolidone) (PVP) was spiked at concentrations of 10 mg l(-1) onto the FBBR run with river water and the biodegradation monitored after lyophilization of aliquots of the test liquor applying MALDI-TOF-MS. The latter proved to be a powerful tool for qualitative screening purposes of PVP in a molecular mass range <20 kDa in particularly yielding a high sensitivity and shot-to-shot reproducibility. The sample-to-sample reproducibility was enhanced applying the anchor target device. Post-source decay-MALDI-TOF-MS fragmentation investigations determined the unknown end groups of PVP unambiguously. Poor biodegradability of PVP can be assumed, since even after 30 days, no oxidation of the terminal groups and no difference in the repeating units was observed. A decrease in the molecular mass distribution can be drawn back rather to adsorption of PVP in the FBBR other than to biodegradation. This was further investigated performing an adsorption experiment with sewage sludge as solid matrix and analyses of the aqueous phase and sludge samples. Extrapolating these results to the situation in wastewater treatment plants, it is highly likely that PVP is eliminated from the dissolved phase by adsorption onto sludge particles.

Electrospray ionization mass spectrometric studies on the amphoteric surfactant cocamidopropylbetaine

After liquid chromatographic (LC) separation, electrospray ionization mass spectrometry (ESI-MS) was investigated for the determination of the amphoteric surfactant cocamidopropylbetaine (CAPB). In the positive ion mode the molecule formed the adduct ions [M + H](+), [M + Na](+) and [M + K](+). Adducts of these cations were also detected with decreasing abundance as dimer and trimer clusters. Additionally, doubly charged molecular ions with different combinations of cations were identified. It was noticed that the relative abundances of individual cation adducts were not reproducible, apparently owing to varying contents of alkali metal ions originating from the solvent and the sample. Under negative ionization, the major molecular ion was [M - H](-). Higher clusters formed by two and three surfactant molecules, i.e. [2M - H](-) and [3M - H](-) were likewise registered. The tendency to form clusters in both positive and negative ion modes, even at 0.1 mg l(-1) levels, was attributed to strong electrostatic interactions between the zwitterionic head groups. Further evidence for this assumption was provided by the detection of a fragment formed from [2M - H](-) which contained the two charged head groups. Studies were undertaken in the negative ion mode on the concentration- and orifice voltage-dependent monomer, dimer and trimer formation of C(12)-CAPB in order to evaluate potential issues in using the ion [M - H](-) mode for quantitative analysis. Finally, the established (-)-LC/ESI-MS method was applied to follow up the primary degradation of CAPB in a laboratory-scale fixed-bed bioreactor (FBBR) spiked with a test concentration of 10 mg l(-1). Direct analysis without sample pretreatment revealed that higher alkyl homologues were more prone to adsorption. Primary biodegradation of all alkyl homologues was completed after a period of 4 days. Selected lyophilized FBBR samples were examined for the presence of transient or stable degradation intermediates, but no metabolite could be identified.

Occurrence and fate of linear and branched alkylbenzenesulfonates and their metabolites in surface waters in the Philippines

Laguna de Bay in the Philippines is one of the largest freshwater lakes in Asia and is considered a primary source of drinking water, but also receives daily discharges of effluent from both domestic and industrial activities. Branched alkylbenzenesulfonates (ABS), which were banned in Europe and withdrawn from the market in the U.S. since the mid-1960s, but not in Southeast Asia, and linear alkylbenzenesulfonates (LAS) are anionic surfactants used in detergent formulations and are therefore main components of effluent discharges. The presence of both LAS and ABS in several water streams in the catchment area of Laguna de Bay was determined using liquid chromatography-mass spectrometry (LC-MS). The concentration levels of LAS (1.2-73 and 2.2-102 microg l(-1)) and ABS (1.1-75 and 1-66 microg l(-1)) in some tributaries of Laguna de Bay and its outlet (Pasig River) to Manila Bay were assessed in December 1999 and March 2000, respectively. The LAS/ABS ratio was calculated as an indication of the extent of the distribution and fate of these surfactants in the surface water. The nearer the location to the metropolitan area of Manila, the higher the levels of LAS and ABS detected in the waters. Moreover, the extent of biodegradation was investigated by monitoring their alkyl homologue distribution and the presence of sulfophenylcarboxylate (SPC) metabolites. Similarly, differences in the levels of SPC and the homologues were apparent at the different sampling points. Presumably, even the quite recalcitrant ABS form SPCs under the conditions present in Southeast Asia. Since wastewater treatment facilities are not well established in developing countries like the Philippines, the call for the use of environmentally friendly chemicals is of even higher significance.

Inter-laboratory comparison of liquid chromatographic techniques and enzyme-linked immunosorbent assay for the determination of surfactants in wastewaters

Seven laboratories participated in an inter-laboratory comparison exercise within the framework of the PRISTINE, SANDRINE and INEXsPORT European Union Projects. Solid-phase extraction (SPE) methodologies were used for the extraction of target analytes from wastewaters. The analytical strategies were based on liquid chromatography (LC) coupled to mass spectrometric (MS) or to fluorescent (FL) detection in all cases with the exception of one laboratory using a test-tube enzyme-linked immunosorbent assay kit. Samples were spiked with the surfactants nonylphenolpolyglycol ether, coconut diethanolamide, linear alkylbenzene sulfonate, nonylphenolpolyglycol ether sulfate, alkylpolyglycol ether and secondary alkane sulfonate. After enrichment on previously conditioned SPE cartridges, the SPE cartridges were distributed among the participating laboratories without the information about the amount of spiked surfactants. In addition, SPE cartridges loaded with a real-world environmental sample containing a tannery wastewater were also analyzed. The results of the programme showed that SPE followed by LC-MS techniques are reliable for the surfactants determination at submicrogram to microgram per liter levels in wastewaters. Inter-laboratory precision values were calculated as the reproducibility relative standard deviation (RSD(R)) which was determined from the reproducibility standard deviation (sR) and the average concentration at a particular concentration level. When data from all laboratories were pooled, the RSD(R) values ranged from 5.1 to 28.3% for the determination of target analytes. The most accurate result corresponded to that given for linear alkylbenzene sulfonates. Taking into account that different methodologies were used (including non-chromatographic techniques) and the complexity of the samples analyzed, it can be considered that acceptable reproducibility values were obtained in this inter-laboratory study.

Determination of linear alkylbenzenesulfonates in wastewater treatment plants and coastal waters by automated solid-phase extraction followed by capillary electrophoresis-UV detection and confirmation by capillary electrophoresis-mass spectrometry

Linear alkylbenzenesulfonates (LASs) were determined in wastewaters and coastal waters by solid-phase extraction, using two different sample preparation protocols depending on the sample treated, followed by capillary electrophoresis and ultraviolet detection (CE-UV). The linear range of the proposed method varied from 3 to 53 and from 25 to 495 microg/l, depending on the compound, with a limit of detection of 1 microg/l when 250 ml of coastal water was preconcentrated. [M-H]- ions were used for CE-MS confirmation after quantification by CE-UV. CE-MS diagnostic ions were the same ones used in LC-electrospray (ESI) MS and corresponded to m/z 297, 311, 325 and 339 for C10, C11, C12 and C13 LASs, respectively. LASs were determined in wastewater samples of the influent and effluent of three wastewater treatment plants (WWTPs), two of them using biological treatment with secondary settlement and receiving mainly domestic wastewaters whereas one of the plants was operated with physicochemical treatment and received mainly industrial wastewaters. LASs were also analyzed in two samples from coastal waters of the bay of Cadiz (Spain) receiving untreated domestic effluents. All samples were also analyzed by LC-ESI-MS and the results are compared with the CE-UV method developed in this work. The concentration levels of total LASs varied from 988 to 1309 microg/l in the influents of WWTPs, whereas in the effluents the concentrations varied from 136 to 197 microg/l. The levels of LASs in coastal wastewaters of the bay of Cadiz varied from 739 to 911 microg/l, indicating that the wastewaters discharged into the bay did not undergo any treatment at all.

Fate studies of the non-ionic surfactant alkyl glucamide by liquid chromatography/electrospray mass spectrometry

Alkyl glucamides (AGs) were analyzed by reversed-phase liquid chromatography (LC) coupled to mass spectrometry with electrospray ionization (ESMS). Analytes were separated according to the chain length of two homologs, C12- and C14-glucamide. Mass spectrometric detection in the positive ion mode exhibited higher overall sensitivity where, apart from fragments, different molecular and quasi-molecular ions were obtained. However, application of the negative ion mode offered advantages in terms of reproducibility and extent of information when analyzing environmental samples. Therefore, a simple and sensitive analytical methodology was developed for the determination of AGs in municipal sewage treatment plant influent and effluent based on solid-phase enrichment, LC separation and negative ion ESMS quantification. After preconcentration of 100 ml of aqueous sample, the recoveries using polymeric LiChrolut EN cartridges exceeded 89%. A quantification limit of 0.1 microg l(-1) was achieved. Studies on the biodegradability and metabolic pathway of C10-glucamide were carried out on a laboratory-scale microbial test unit under aerobic conditions. A postulated metabolism including omega-oxidation of the alkyl chain followed by subsequent beta-oxidations was checked by LC/ESMS. Identification and formation of 'C4-glucamide acid' as a degradation intermediate was confirmed by mass spectrometric studies. Higher homolog acids such as C10-, C8- and C6-glucamide acids, which should be predicted precursors of C4-glucamide acid, and any other metabolites, were not detectable, presumably owing to rapid breakdown.

Investigations on the metabolism of alkyl polyglucosides and their determination in waste water by means of liquid chromatography-electrospray mass spectrometry

Alkyl polyglucosides (APGs) were analyzed by reversed-phase liquid chromatography coupled to mass spectrometry with electrospray ionization. Analytes were separated according to the chain length of the alkyl homologues, whereas the separation of isomeric forms of the glucose moiety was achieved partially. Depending on the structure of the glucose ring the alkyl monoglucosides show a distinct affinity in terms of the formation of sodium and ammonium adduct ions. Metabolism of isomer pure alkyl monoglucosides was studied on a testfilter device to gather information about the degradation behavior and to obtain eventually poorly degradable metabolites. In spite of unsuccessful detection of any metabolites such as "polyglucoside alcanoic acids", a degradation pathway was proposed including the cleavage of the glucosidic bond as initial step. In addition, a method for the determination of APGs in municipal waste water effluent was developed using solid-phase extraction on reversed-phase material. Recovery rates were in the range of 66 to 98% for three spiked alkyl monoglucosides and a quantitation limit of 0.2 microg l(-1) was achieved.

[ARDS and Wegener granulomatosis]

Wegener's granulomatosis is a distinct clinicopathologic entity characterized by granulomatous vasculitis of the upper and lower respiratory tract and glomerulonephritis. This disease can present as a clinical picture which resembles sepsis and adult respiratory distress syndrome (ARDS). Wegener's disease requires immunosuppression which can have detrimental consequences when used in sepsis. The following case report illustrates the diagnostic difficulties encountered by intensive care physicians treating severe pulmonary failure and multiple organ dysfunction in Wegener's granulomatosis appearing as ARDS with sepsis.

CASE REPORT

A 19-year-old female patient had developed acute respiratory and renal failure after a prolonged period (many months) of antibiotic resistant otitis, sinusitis and mastoiditis. The patient had required intubation at another hospital and there was a history of tension pneumothorax and cardiopulmonary resuscitation during mechanical ventilation. Emergency extracorporeal membrane oxygenation (ECMO) for acute hypercapnic and hypoxic respiratory failure was instituted and the patient was transported to our institution while on ECMO. The patient was treated empirically for suspected pulmonary and systemic infection and received hydrocortisone (0.18 mg/kg/h) as part of a protocol-driven treatment of septic shock in addition to antibiotic and antimycotic regime. The use of ECMO was required for 10 and mechanical ventilation for another 50 days after admission. After successful extubation, central nervous system dysfunction became evident with a somnolent and generally unresponsive patient. When the hydrocortisone dose was gradually tapered, the clinical status of the patient further deteriorated, pulmonary gas exchange worsened and she developed renal failure with proteinura and hematuria. A renal biopsy was performed demonstrating vasculitis and focal segmental glomerulonephritis, a systemic granulomatous vasculitis was suspected; the serum was tested for anti-proteinase 3 antibodies (PR3-ANCA) and turned out to be positive (17.5 U/ml; normal range < 7 U/ml). The morphologic findings from renal biopsy, the positive test for antiproteinase 3 antibodies and the pulmonary-renal involvement with evidence of multisystem disease established the diagnosis of Wegener's granulomatosis. Immunosuppressive therapy with cyclophosphamide and prednisolone was instituted resulting in rapid improvement with recovery of pulmonary, renal and central nervous system function within two weeks. The use of ECMO in this patient served as a life-saving immediate measure usefull to "buy time" until a definite diagnosis could be established. ARDS represents an uniform pulmonary reaction to a large number of different noxious stimuli and disease entities. This case demonstrates that intensive care physicians caring for critically ill patients with ARDS should include even rare causes of pulmonary injury into their differential diagnosis.

[Abnormalities of the atrial septum in adults: kind, prevalence and clinical relevance]

To classify interatrial septal anomalies in adults, 24,458 Doppler-echocardiographic studies performed between 1. 1. 1987 and 31. 12. 1992 were reviewed. Patients below 16 years of age or with complex congenital heart disease, or after surgical closure of an atrial septal defect, were excluded. Additionally, all 823 transesophageal echocardiographies done between 1. 1. 1993 and 31. 12. 1994 were analyzed to see whether a patent foramen ovale was present. Among 294 patients with interatrial septal anomalies (prevalence 1.2%; male:female = 1:1.4), 298 congenital anomalies of the interatrial septum were detected. 63% of interatrial septal anomalies constituted newly detected anomalies. Age ranged from 16 to 84 (median 43) years. In 21% of the patients the left-to-right shunt was > or = 50% (QP/QS > or = 2). In 25% pulmonary hypertension was present and 25% of the patients underwent surgery. A patent foramen ovale was present in 0.16% of all transthoracal and in 5.7% of all transesophageal echocardiographies. Secundum defects constituted 46%, atrial septal aneurysms 24%, patent foramen ovale 13%, atrioventricular canals 11%, and superior sinus venosus defects with anomalous pulmonary venous return 6% of all diagnoses. Associated anomalies were mitral valve prolapse in 14%, pulmonary valve stenosis in 3%, left-sided persistent vena cava superior and Chiari network in 2% each, anomalous pulmonary venous return, ventricular septal defect, bicuspid aortic valve, and Ebstein's anomaly in 1% each. 4% of the patients showed further cardiac lesions.

CONCLUSIONS

Anomalies of the interatrial septum in adults were frequent and often newly detected. In a high percentage of patients with interatrial septum the left-to-right shunt was hemodynamically relevant.

Proopiomelanocorticotropin (POMC) peptides and lipoprotein lipase activity in vitro

Effects of alpha-melanocyte-stimulating hormone (alpha-MSH), beta-melanocyte-stimulating hormone (beta-MSH), beta-lipotropin (beta-LPH), and beta-endorphin (beta-EPH) at concentrations from 10(-9) M up to 10(-6) M on human adipose tissue lipoprotein lipase (LPL) were studied in a cell-free system. alpha-MSH and beta-MSH did not exert any effect on LPL; no degradation of these peptides in the incubation medium could be detected by HPLC analysis. beta-LPH and beta-EPH failed to alter enzyme activity. However, HPLC analysis revealed an unspecific rapid degradation of the peptides due to the activity of tissue proteases. Therefore, the protease inhibitors amastatin, antipain, APMSF, and TPCK were tested at concentrations of 10(-5), 10(-4), and 10(-3) M for their efficacy to inhibit degradation. None of the inhibitors was able to substantially reduce proteolysis of beta-LPH, as was the case with amastatin, APMSF, and TPCK for beta-EPH. However, antipain at 10(-4) M preserved at least 20% of the initial peptide concentration from proteolysis up to 150 min. Antipain caused a decrease in lipoprotein lipase activity (LPLA), which was dependent on concentration. The adverse effect of antipain at concentrations of 10(-4) M on LPL was completely abolished by beta-EPH at a concentration of 10(-6) M.

Congenital cleft of the anterior tricuspid leaflet with severe tricuspid regurgitation in adults

OBJECTIVES AND BACKGROUND

Severe primary tricuspid regurgitation in the adult is a rare finding. This study describes the diagnostic findings and the treatment of an isolated congenital cleft of the anterior leaflet of the tricuspid valve as the morphologic substrate for severe tricuspid regurgitation.

METHODS

The clinical, echocardiographic findings and the follow-up findings of five patients (all male, 20 to 56 years old) with this disorder are described. Four of the five patients underwent cardiac surgery that confirmed the diagnosis.

RESULTS

In three of five patients, exertional fatigue was the limiting symptom (New York Heart Association functional classes II and III). The clinical findings included a holosystolic murmur and supraventricular arrhythmias in all patients. Cardiac catheterization, performed in four patients, yielded the incorrect diagnosis of Ebstein's anomaly in three. In one patient the cleft was associated with an atrial septal defect of the secundum type. In four of five patients successful reconstruction of the tricuspid valve with a DeVega annuloplasty was performed. One patient had a partial excision of the right atrium, and one had a closure of a coexisting atrial septal defect. One patient refused operation.

CONCLUSIONS

Tricuspid valve anomalies can be accurately identified by Doppler echocardiography. Surgical repair is the treatment of choice in patients with severe tricuspid regurgitation due to a congenital cleft of the anterior leaflet of the tricuspid valve.

[Congenital heart defects and abnormalities newly detected with echocardiography in adolescents and adults]

In 12,576 consecutive Doppler-echocardiographic studies (DE) performed on 11,450 patients over 3 years (1987-1989), 183 newly diagnosed congenital heart abnormalities were detected in 161 patients. The age of the 161 patients (86 female, 75 male) ranged from 16 to 84 years (median 34.5). The highest incidences of pathologies were those of ASD II (29%) and VSD (11%). With decreasing frequency the following abnormalities were diagnosed: pulmonary valve disease (8%), interatrial septal aneurysms (7%), membranous subvalvular aortic stenosis (5%), anomalous pulmonary venous connections (4%), atrioventricular canal defects (4%), persistent left superior venae cavae (4%), patent ductus arteriosus (4%), aneurysms of the membranous septum (4%), and sinus venosus defects (3%). Less common findings were coarctation of the aorta (2.5%), persistent sinusoids (2.5%), arteriovenous fistulas (2.5%), congenital LV-aneurysms (2.5%), Ebstein's anomalies (1%), anomalies of the papillary muscles (1%) and RV-dysplasias (1%). Rare findings were a cor triatriatum, a tetralogy of Fallot, a partial defect of the pericardium, a pulmonic atresia with VSD, an isolated cleft of the tricuspid valve, and finally a connection of a hepatic vein to the right atrium. In conclusion, we found an incidence of 1.4% in newly diagnosed congenital heart disease in adolescents and adults undergoing DE. 32 of 159 patients (20%) were referred to surgery, while endocarditis prophylaxis was indicated in 45%.

A Practical Guide to the Developmental Biology of Terrestrial-Breeding Frogs

Many frogs lay their eggs in water; the development of these frogs is well-known. However, many frogs reproduce on land; their eggs are large and have an altered early development. As examples, Gastrotheca riobambae broods its embryos in a pouch on the mother's back, and Eleutherodactylus coqui exhibits direct development with no tadpole stage. We provide practical information on obtaining eggs and embryos from these terrestrial-breeding species and on analyzing their development. Our aim is to make these species more accessible to researchers who are interested in the developmental and evolutionary consequences of terrestrial development.

[Mortality in 709 patients with acute myocardial infarct treated in the intensive care unit]

To control the quality of our care and to define the potential for lifesaving early intervention in patients with acute myocardial infarction, we analyzed the course of 709 patients (66.4 +/- 10.8 yrs) admitted to the coronary care unit for acute myocardial infarction over a period of 36 months. 77 patients (70.2 +/- 9.3 yrs) died in the coronary care unit, and thus early mortality was 10.9%. Only 8% died from disturbances of cardiac rhythm and 19% from rupture of a ventricle. 73% died in cardiogenic shock, of whom 21 were below 70 years old and represent a potential group for early intervention. In 13 patients of this subgroup possibilities of better management in the pre-hospital phase were found retrospectively. In 5/77 patients the optimal treatment was not achieved during clinical course. Cardiogenic shock is the major cause of death in the early phase of acute myocardial infarction. A further substantial reduction of mortality will be achieved only by reaching more risk patients in the pre-infarction phase and by shortening the pre-hospital phase.

[Diabetes insipidus in chronic myeloid leukemia. Remission of hypophyseal infiltration during busulfan treatment]

In a 53-year-old male who presented with diabetes insipidus as the first symptom of chronic myelocytic leukemia, computed tomography of the sella showed infiltration of the posterior pituitary gland. Busulfan treatment was given for one month and the infiltration had disappeared ten weeks after initiation of therapy. At the same time the severity of the diabetes insipidus diminished for a period of three months. Diabetes insipidus is a rare complication of chronic myelocytic leukemia: only 8 similar cases have been reported in the last 75 years.

Haemodynamics at rest and during isometric exercise under long-term treatment with captopril in dilated and ischaemic cardiomyopathy

In the present study 12 patients with severe chronic heart failure (7 with dilated cardiomyopathy and 5 with ischaemic heart disease) underwent right heart catheterization at rest and during isometric exercise by handgrip before and 6 months after treatment with captopril (mean dose 2 X 39.6 mg/day) while concomitant digitalis and diuretics were unchanged. After 6 months resting haemodynamics changed as follows: decrease in heart rate, mean arterial pressure, pulmonary capillary pressure and total vascular resistance; increase in stroke volume index and stroke work index. During handgrip the following changes were observed after captopril: decrease in total vascular resistance; increase in stroke volume index and stroke work index. Before captopril 11 patients showed no increase or even a decrease in stroke work index during isometric exercise, whereas after captopril 5 out of the 12 patients showed an increase in stroke work index. The results demonstrate that in patients with severe chronic heart failure long-term treatment with captopril lowers preload and afterload, which is accompanied by a significant improvement in left ventricular performance at rest. Furthermore, during isometric exercise after captopril an improvement in left ventricular function was found in 5 out of 12 patients.

[Rest and effort hemodynamics during long-term treatment of dilated and ischemic cardiomyopathy with captopril]

In the present study 13 patients with severe chronic heart failure were investigated by right heart catheterization at rest and during handgrip before and 6 months after treatment with captopril (mean dose 2 X 37.5 mg per day). Before initiating captopril therapy all patients were clinically stable on digitalis and diuretics. During the observation period 3 patients died suddenly. Of the remaining cases, 5 had dilated cardiomyopathy and 5 ischemic heart disease. After 6 months, resting hemodynamic measurements changed as follows: systemic vascular resistance decreased from 1594 to 1284 dyn X sec X cm-5 (p less than 0.005), left ventricular end-diastolic pressure decreased from 17 to 10 mm Hg (p less than 0.01) and stroke volume index increased from 32 to 40 ml/m2 (p less than 0.05). Before captopril, 9 patients showed no increase or even a decrease of stroke work index during isometric exercise, whereas after captopril 5 out of the 10 patients showed an increase in stroke work index. The results demonstrate that, in patients with severe chronic heart failure, long-term afterload reduction with captopril is accompanied by a significant improvement in left ventricular performance at rest. Furthermore, during isometric exercise after captopril an improvement in left ventricular function was found in 5 out of 10 patients.

[Diagnosis, etiology and clinical course of acute and chronic pericarditis]

Between 1976 and 1982 18 patients with acute and 13 with chronic pericarditis (excluding constrictive pericarditis) were seen at the Medical Outpatient Clinic, University Hospital, Zürich. The prominent symptom in acute pericarditis was chest pain (15/18 patients versus 0/13 in chronic pericarditis, p less than 0.001) and in chronic pericarditis dyspnea (7/13 patients versus 1/18 in acute pericarditis, p less than 0.005). Pericardial friction rub and ST elevation were significantly more frequent in acute than in chronic pericarditis. In contrast, elevation of venous pressure occurred more often in the chronic than in the acute form. During the follow-up of 3.2 years the NYHA class decreased from 2.5 to 1.2 (p less than 0.001) in the group with acute pericarditis although 7 recurrences occurred in 3 patients within the first two years. The follow-up in the patients with chronic pericarditis was 4.4 years and the NYHA class decreased from 2.4 to 1.4 (p less than 0.05). There were, however, two deaths in the group with chronic pericarditis and pericardiocentesis and/or pericardiectomy had to be performed in 8/13 patients.

[Relationships between hemodynamic values with prognostic significance and morphology of the left ventricle in patients with aortic insufficiency]

Hemodynamic parameters have recently been described which are of prognostic importance for the outcome of valve replacement in patients with aortic insufficiency. It was investigated whether pathological values for the left ventricular end-systolic volume index, the ejection fraction, the end-diastolic radius/wall thickness ratio, the end-systolic diameter (DS) and shortening of the diameter (Sh), and the end-diastolic volume index are accompanied by morphological alterations evaluated from left ventricular endomyocardial biopsies. Hypertrophy of the cardiac fibers was significantly increased in patients in whom preoperative Sh was less than 25% and DS greater than 55 mm. In contrast, left ventricular interstitial fibrosis did not differ between these patients and those with Sh greater than or equal to 25% and DS less than or equal to 55 mm.