Vitreous humor in the forensic toxicology of quetiapine and its metabolites

PURPOSE

Τhe aim of the present study was to investigate the use of vitreous humor as an alternative biological material in forensic toxicology for the determination of quetiapine, 7-hydroxy-quetiapine, and nor-quetiapine. The distribution of these substances in vitreous humor was studied by determining and correlating their concentrations in vitreous humor with the respective concentrations in blood.

METHODS

During this study, a method for the determination of these substances was developed, validated and applied to postmortem samples obtained from 16 relative forensic cases. The sample preparation procedure included the isolation of the analytes from vitreous humor and blood samples using solid-phase extraction, with Bond Elut LRC C18 columns followed by derivatization with BSTFA with 1% TMCS prior to GC/MS analysis.

RESULTS

The developed method is characterized by a dynamic range of 10.0-1000.0 ng/mL (R2 ≥ 0.991) for the three substances, with a limit of detection and quantification of 3.0 and 10.0 ng/mL, respectively. Accuracy and precision were below 8.09% and 8.99%, respectively, for both biological materials, while absolute recovery for the three substances was greater than 81%. According to the results, quetiapine, 7-hydroxy-quetiapine, and nor-quetiapine are easily distributed in vitreous humor.

CONCLUSION

The results of the study indicate the usefulness of vitreous humor in toxicological analysis for the determination of these substances, especially when the traditional biological materials are not available. The levels of quetiapine and its metabolites in vitreous humor as well as the vitreous humor to blood concentration ratios can provide important information for a more thorough toxicological investigation of forensic cases.

The myosuppressin structure-activity relationship for cardiac contractility and its receptor interactions support the presence of a ligand-directed signaling pathway in heart

The structural conservation and activity of the myosuppressin cardioinhibitory peptide across species suggests it plays an important role in physiology, yet much remains unknown regarding its signaling. We previously reported Drosophila melanogaster myosuppressin (dromyosuppressin, DMS; TDVDHVFLRF-NH₂) decreases cardiac contractility through a G protein-coupled receptor, DMS-R2. Our study showed the DMS N-terminus amino acids influence its structure-activity relationship (SAR), yet how they act is not established. We predicted myosuppressin N-terminal amino acids played a role in signaling. Here, we tested our hypothesis in the beetle, Zophobas atratus, using a semi-isolated heart bioassay to explore SAR in a different Order and focus on cardiac signaling. We generated a series of myosuppressin truncated analogs by removing the N-terminal residue and measuring the activity of each structure on cardiac contractility. While DVDHVFLRF-NH₂ decreased cardiac contractility, we found VDHVFLRF-NH₂, DHVFLRF-NH₂, and HVFLRF-NH₂ increased activity. In contrast, VFLRF- NH₂ decreased activity and FLRF-NH₂ was inactive. Next, we analyzed molecular docking data and found the active truncated analogs interacted with the 3-6 lock in DMS-R2, the myosuppressin cardiac receptor, disrupting the salt bridge between H114 and E369, and K289 and Q372. Further, the docking results showed the inhibitory effect on contractility may be associated with contact to Y78, while the analogs that increased contractility lacked this interaction. The data from our study demonstrated N-terminal amino acids played a role in myosuppressin activity and signaling suggesting the cardiac receptor can be targeted by biased agonists. Our myosuppressin cardiac contractility data and predicted receptor interactions describe the presence of functional selectivity in a ligand-directed signaling pathway in heart.

The use of endocuff for the facilitation of endoscopic mucosal resection in defiant colonic polyps. A case series

BACKGROUND

Endocuff has been suggested as a safe and useful device facilitating complex endoscopic mucosal resection (EMR) in the sigmoid colon; however, the existing data are sparse. In this case series, we report our experience with endocuff in facilitating EMR in defiant polyps throughout the colon.

CASE SERIES

In colonoscopies where sufficient stability and, thus, reliable visualization of the lesion was not possible (defiant polyp), the endoscope was removed, and subsequently, an ENDOCUFF VISIONTM was mounted on its tip. Thereafter, the colonic area of interest underwent endoscopic re-examination. The study prospectively included fifteen patients with 16 sessile/flat polyps. Fifteen of the 16 EMRs were considered successful.

CONCLUSIONS

This case series indicates the use of endocuff as an auxiliary device for facilitating EMR in defiant colonic polyps. HIPPOKRATIA 2021, 25 (3):134-137.

Functioning in community-dwelling patients with schizophrenia spectrum disorders in rural Greece

BACKGROUND

There is a dearth of studies on functioning in patients with psychotic disorders in rural areas.

AIM

The objective of this study was to assess functioning in a population-based sample of patients with psychotic disorders who live in rural, remote and deprived areas in Greece, and to explore the differences in functioning across ages.

METHODS

The sample consisted of 61 patients with psychotic disorders that were engaged to treatment with a community mental health service. The mean age of patients was 54.2 years, and the mean illness duration was 26.5 years.

RESULTS

A total of 23 patients (37.7%) had score in the Global Assessment of Functioning scale >60, and were rated as adequately functioning, and 18 patients (29.5%) had score in Clinical Global Impression scale-Schizophrenia ⩽3 and could be rated as mildly or minimally ill. Functioning was found to be inversely related to the patients' symptomatology. No correlation with age was found.

CONCLUSION

This study suggests that a large proportion of patients with psychotic disorders in rural Greece may achieve a satisfactory level of functioning in the long-term, across the whole age range despite the not completely remitted symptomatology. More research is needed to clarify the factors associated with rural residency that may account for patients' functioning.

A GC-MS method for the determination of furanylfentanyl and ocfentanil in whole blood with full validation

Purpose

Fentanyl analogues are popular in recent years among drug addicts and have been related to many overdoses and deaths worldwide. Furanylfentanyl, ocfentanil, acetylfentanyl and butyrfentanyl are among the most common of these drugs. Methods for the determination of furanylfentanyl and ocfentanil by gas chromatography–mass spectrometry (GC–MS) in biological samples do not exist, and therefore, their development would be extremely useful for routine toxicological analysis.

Methods

A GC–MS method was developed and fully validated for the determination of furanylfentanyl and ocfentanil in whole blood. This method was also suitable for the determination of acetylfentanyl and butyrfentanyl. The method included solid-phase extraction after protein precipitation using acetonitrile, and it was applied during the toxicological investigation of forensic cases. Methadone-d₃ was used as internal standard for the quantification of the analytes.

Results

The limit of detection and limit of quantification values were 0.30 and 1.0 ng/mL for furanylfentanyl and ocfentanil and 0.15 and 0.50 ng/mL for acetylfentanyl and butyrfentanyl, respectively. The calibration curves were linear (R² ≥ 0.993) from 1.00 to 100 ng/mL for furanylfentanyl and ocfentanil and from 0.50 to 50.0 ng/mL for acetylfentanyl and butyrfentanyl. The recoveries were not lower than 85%, while accuracies and precisions were not greater than 6.0% (% error) and 8.0% (% relative standard deviation), respectively, for all four fentanyl analogues.

Conclusions

The developed method is the first one in the literature for the detection of furanylfentanyl and ocfentanil in biological fluids by GC–MS, and it provides very high sensitivity comparable to that by liquid chromatography–tandem mass spectrometry.

Metabolites replace the parent drug in the drug arena. The cases of fonazepam and nifoxipam

Fonazepam (desmethylflunitrazepam) and nifoxipam (3-hydroxy-desmethylflunitrazepam) are benzodiazepine derivatives and active metabolites of flunitrazepam. They recently invaded the drug arena as substances of abuse and alerted the forensic community after being seized in powder and tablet forms in Europe between 2014 and 2016. A review of all the existing knowledge of fonazepam and nifoxipam is reported, concerning their chemistry, synthesis, pharmacology and toxicology, prevalence/use, biotransformation and their analysis in biological samples. To our knowledge, fonazepam and nifoxipam-related intoxications, lethal or not, have not been reported in the scientific literature. All the available information was gathered through a detailed search of PubMed and the World Wide Web.

AH-7921: the list of new psychoactive opioids is expanded

AH-7921 is a structurally unique synthetic opioid analgesic that has recently entered the drug arena in Europe, the USA, and Japan. Although it was synthesized and patented in the mid-1970s, it was first identified in a seized sample purchased via the Internet in July 2012 and formally brought to the attention of the European Union early warning system in August 2012 by the United Kingdom. Several in vitro experiments and animal model studies established the morphine-like analgesic action of AH-7921 as a μ-opioid receptor agonist that has been found to be several times more potent than codeine and at least as potent as morphine. This novel psychoactive substance has already led to eight non-fatal intoxications and 16 deaths in Sweden, the United Kingdom, Norway, and the USA. Thus, AH-7921 is a current public health risk, and better international collaboration, effective legislation and continuous community alertness are needed to tackle this current growing problem. The aim of this review is to summarize the current knowledge about this drug concerning its chemistry, pharmacology, and toxicology, as well as its international legal status. The limited existing analytical methodologies for the determination of AH-7921 in biological samples are also presented. Published or reported AH-7921-related cases, fatalities, or intoxications, and self reports from drug users are reviewed.

A fully validated method for the determination of lacosamide in human plasma using gas chromatography with mass spectrometry: application for therapeutic drug monitoring

A simple gas chromatographic method with mass spectrometry detection was developed and validated for the determination of lacosamide in human plasma. Lacosamide and the internal standard, levetiracetam-d6, were extracted from 200 μL plasma, by a solid-phase extraction through HF Bond Elut C18 columns, and derivatized using N-methyl-N-tert-butyldimethylsilyltrifluoroacetamide with 1% tert-butyldimethylsilylchloride in acetonitrile. The limit of quantification was found to be 0.20 μg/mL and the assay was linear up to 20.0 μg/mL with correlation coefficient ≥0.994. The intra- and interday precision values were <4.1% in terms of relative standard deviation (%) and the values of intra- and interday accuracy were found to be within -7.2 and 5.3% in terms of relative error (%). Absolute recovery of the method for lacosamide was determined at three concentration levels and ranged from 92.5 to 97.6%. The developed method uses small volumes of plasma and proved to be simple, rapid, and sensitive for the determination of lacosamide in plasma. This method can be used in routine every day analysis of plasma samples obtained from patients who follow respective antiepileptic treatment and for the investigation of clinical and forensic cases where lacosamide is involved.

A validated GC/MS method for the determination of amisulpride in whole blood

A sensitive GC/MS method for the determination of amisulpride in whole blood was developed, optimized and validated. Sample preparation included solid-phase extraction using HF Bond Elut C18 cartridges and further derivatization with heptafluorobutyric anhydride (HFBA). The limits of detection and quantification were 3.00 and 10.0 μg/L, respectively. The calibration curves were linear up to 1000 μg/L (R(2)≥0.991). Absolute recovery ranged from 94.2 to 101%. Accuracy was found to be between -8.7 and 1.9% and imprecision was less than 10.0%. The developed method covers the generally accepted therapeutic range but it can also cover levels above them. This makes our method suitable for the determination of amisulpride not only for clinical purposes on psychiatric patients, but also during the investigation of forensic cases where amisulpride is involved.

First systematic evaluation of the potency of Cannabis sativa plants grown in Albania

Cannabis products (marijuana, hashish, cannabis oil) are the most frequently abused illegal substances worldwide. Delta-9-tetrahydrocannabinol (THC) is the main psychoactive component of Cannabis sativa plant, whereas cannabidiol (CBD) and cannabinol (CBN) are other major but no psychoactive constituents. Many studies have already been carried out on these compounds and chemical research was encouraged due to the legal implications concerning the misuse of marijuana. The aim of this study was to determine THC, CBD and CBN in a significant number of cannabis samples of Albanian origin, where cannabis is the most frequently used drug of abuse, in order to evaluate and classify them according to their cannabinoid composition. A GC-MS method was used, in order to assay cannabinoid content of hemp samples harvested at different maturation degree levels during the summer months and grown in different areas of Albania. This method can also be used for the determination of plant phenotype, the evaluation of psychoactive potency and the control of material quality. The highest cannabinoid concentrations were found in the flowers of cannabis. The THC concentrations in different locations of Albania ranged from 1.07 to 12.13%. The influence of environmental conditions on cannabinoid content is discussed. The cannabinoid content of cannabis plants were used for their profiling, and it was used for their classification, according to their geographical origin. The determined concentrations justify the fact that Albania is an area where cannabis is extensively cultivated for illegal purposes.

A fully validated method for the simultaneous determination of 11 antidepressant drugs in whole blood by gas chromatography-mass spectrometry

Antidepressant drugs are widely used for the treatment of depression and other psychiatric disorders and as a result they are involved in numerous clinical and forensic cases. The aim of this study was the development, optimization and validation of a simple, specific and sensitive GC/MS method for the simultaneous determination of 11 antidepressant drugs and 4 of their metabolites (amitriptyline, citalopram, clomipramine, fluoxetine, fluvoxamine, maprotiline, desmethyl-maprotiline, mirtazapine, desmethyl-mirtazapine, nortriptyline, paroxetine, sertraline, desmethyl-sertraline, venlafaxine and desmethyl-venlafaxine) in whole blood. The combination of solid-phase extraction with derivatization using heptafluorobutyric anhydride efficiently reduced matrix effect and improved sensitivity of the method. In this assay, protriptyline was used as internal standard. Absolute recovery values for all analytes were ranged from 79.2 to 102.6%. LODs and LOQs were found to be between 0.30-1.50 μg/L and 1.00-5.00 μg/L, respectively. The calibration curves were linear (R(2)≥0.990) within the range of 5.00-1000 μg/L for all analytes. Accuracy expressed as the % E(r) was found to be between -12.3 and 12.2%. Precision expressed as the % RSD was found to be less than 11.7% for all antidepressants. The developed method proved to be suitable for routine work and it was used to successfully analyze more than 2500 clinical and forensic blood samples.

Development and validation of a method for the determination of buprenorphine and norbuprenorphine in breast milk by gas chromatography-mass spectrometry

Buprenorphine (BUP) is used for the maintenance of opioid-addicted pregnant women. Because BUP and its main metabolite nor-BUP are excreted into breast milk, a sensitive and specific GC/MS method has been developed, optimized and validated for their determination in breast milk. BUP-d4 was used as internal standard. The sample preparation includes combination of protein precipitation with solid-phase extraction and derivatization (acetylation). The absolute recovery for both analytes was found to be higher than 87.3%. The limits of detection and quantification were 0.07 and 0.20 µg/L, respectively. The calibration curves were linear within the dynamic range 0.20-20.0 µg/L, with a correlation coefficient higher than 0.996. Intra- and inter-day accuracies were ranged from -7.06 to 4.50 and from -5.88 to 7.00%, respectively, while intra- and inter-day precision were less than 5.7 and 6.1%. The analytes were found to be stable in breast milk at 4 °C for one week, at -20 °C for one month, and after three freeze-thaw cycles. The method can be used for the determination of BUP and nor-BUP in breast milk of BUP-maintained mothers, in order to calculate the amount of drug that could pass to the newborn via breast milk and to avoid toxic consequences of breastfeeding.

A fully validated method for the determination of vardenafil in blood using gas chromatography/mass spectrometry

Vardenafil (VDN) is one of the three commercially available phosphodiesterase type 5 inhibitors and it is mainly used in the treatment of erectile dysfunction. A sensitive and specific gas chromatography/mass spectrometry (GC/MS) method for the determination of VDN in blood has been developed and validated. Sample preparation included solid-phase extraction and derivatization with N-methyl-N-tert-butyldimethylsilyl-trifluoroacetamide (MTBSTFA) and 1% tert-butyldimethylsilylchloride (TBDMSCl). Protriptyline was used as the internal standard for this assay. Limits of detection and quantification for VDN were 0.70 and 2.00 µg/l, respectively. The calibration curves were linear within the dynamic range 2.00-200.0 µg/l with a correlation coefficient higher than 0.991. Absolute recovery ranged from 88.6% to 95.7% for the analyte of interest at three quality control levels. Intra- and inter-day accuracy was found to be between - 6.1% to 10.8% and - 9.3% to 11.6%, respectively, whereas intra- and inter-day precision was < 7.8% and 9.7%, correspondingly. The proposed method is the first fully validated GC/MS method for the determination of VDN in blood samples and it can be used in routine every day analysis by clinical and forensic laboratories for pharmacokinetic studies, for therapeutic drug level monitoring or for the investigation of related forensic cases. A few blood samples analyzed using the developed method is reported herein to demonstrate the suitability of the method.

Chromogranin a levels in diagnosis, treatment and follow-up of 42 patients with non-functioning pancreatic endocrine tumours

BACKGROUND/AIMS

Non-functioning pancreatic endocrine tumours (NFPET) constitute the largest component (35-50%) of pancreatic endocrine tumours. They are characterized by the absence of symptoms of hormone hypersecretion and frequently have clinical manifestations similar to the more common exocrine pancreatic adenocarcinoma. The present studyaims toevaluate the clinical features, diagnostic approach and, in particular, the significance of serum chromogranin A levels (CgA) in the management and outcome of 42 patients with NFPET (from a series of 121 patients with pancreatic endocrine tumours).

METHODS

Twenty-five males and 17 females were included, and the mean age at diagnosis was 52.3 years (range: 26-68 years). The diagnosis for each patient was established by histopathological examination and immunohistochemistry. After the histopathological confirmation of diagnosis and during the follow-up period, patients were evaluated clinically and radiologically (including OctreoScan), whilst fasting gut hormones (including CgA) were also estimated. At diagnosis, all patients were checked for the presence of multiple endocrine neoplasia type I syndrome. The follow-up was complete and ranged from 12 to 86 months (mean: 49 months).

RESULTS

Dyspepsia (66.5%) and weight loss (47.6%) were the most common symptoms at diagnosis, while in 21.4% of patients tumour lesions were revealed incidentally. Plasma CgA levels were significantly or moderately elevated in all patients with liver metastases at diagnosis (64.3%). The levels also reflected tumour progression or response to treatment during the follow-up period. OctreoScan showed avid uptake in 77.8% of patients with hepatic metastases. Moreover, in 2 patients OctreoScan revealed unexpected metastatic mesenteric deposits, which had not been found by the other studies. However, it was negative in 6 patients with liver metastases, in whom tumours were proved to be poorly differentiated (high-grade).

CONCLUSIONS

(1) NFPET may present with clinical manifestations similar to those of an exocrine pancreatic tumour; (2) plasma CgA levels reflect tumour load, and also seem to correlate with tumour progression or response to treatment; (3) surgeryin patients with localized disease at presentation can be curative, while it can also reduce tumour burden in patients with metastases; (4) long-acting somatostatin analogues provide good quality of life and temporary disease stabilization in patients with low-grade tumours; (5) systemic chemotherapy or chemoembolization seem to be beneficial in high-grade and progressive tumours.

Gastrinomas associated with MEN-1 syndrome: new insights for the diagnosis and management in a series of 11 patients

BACKGROUND/AIMS

Approximately, 25-30% of patients (pts) have gastrinomas, (Zollinger-Ellison syndrome, ZES), as part of the inherited syndrome, multiple endocrine neoplasia 1 (MEN-1). The identification of MEN-1 syndrome in these pts is always important, as there are some differences in their management and prognosis. Among 33 pts with ZES, we present in this study 11 pts with ZES and MEN-1 syndrome, describing our diagnostic and therapeutic approach.

METHODOLOGY

Eleven pts with ZES and MEN-1 syndrome (6 females and 5 males) were included (mean age 51.8 years). The diagnosis of ZES was based upon: a) clinical features and b) high serum gastrin levels, while in 7/11 pts diagnosis was confirmed histopathologically. A variety of other gastrointestinal peptides, as well as the general neuroendocrine tumor marker, Chromogranin-A (CgA) were also estimated. All pts underwent conventional imaging methods (CT, MRI) and OCTREOSCAN or EUS when necessary, in order to localize the primary lesion or the metastases. The diagnosis of MEN-1 was based upon the presence of the other two MEN-1 related endocrinopathies (hyperparathyroidism, pituitary adenomas), revealed by estimation of several hormones (PTH, Prolactin, ACTH etc.) and performance of imaging studies of the pituitary and parathyroid glands. When MEN-1 syndrome was established, a familiar screening of pts was also performed, when possible. The mean duration of pts' follow-up was 6.1 years (range: 2.1-8.5 years).

RESULTS

At the time of presentation, 91% pts, had symptoms of peptic ulcer disease, refractory to treatment, while a history of colicky abdominal pain due to nephrolithiasis was also reported by 45% pts. Four of our pts had a blood relation. Serum gastrin levels at the time of diagnosis were greater than 1000pg/mL in 63.5% pts, while at the same time serum CgA levels were greater than 10 times the upper normal limit (<98ng/mL) in all pts. OCTREOSCAN and EUS revealed the primary tumor (in duodenum or pancreas) in 64% pts, in whom conventional methods showed no abnormalities at the same time. Parathyroid adenomas, pituitary adenomas and bronchial carcinoids were revealed in 11, 3 and 1 pts respectively, which were treated surgically. Also, surgical treatment of pancreatic or duodenal gastrinomas was performed in 54.5% pts, while pts who already had metastases (45%), or developed them during the follow-up period (18%), were treated by somatostatin analogues (63.6%) and chemotherapy (27.3%). Ten out of 11 pts are alive and in a good condition, whereas 1 patient died 2.8 years after diagnosis. Familiar screening revealed parathyroid adenomas in 4 children of our pts, which were treated surgically.

CONCLUSIONS

MEN-1 syndrome should always be considered in pts with ZES. A precise preoperative localization of all pancreaticoduodenal lesions, in combination with a surgical exploration and management by experienced surgeons, seems to be curative in pts without distal metastases. Non-surgical treatment with somatostatin analogues and chemotherapy in pts with progressive disease seem to stabilize the disease, although further studies are needed. A close clinical and biochemical follow-up of all pts, as well as their family members, is necessary in order to reveal and treat all MEN-1 related endocrinopathies and especially PETs, in an early stage.

VIPomas: an update in diagnosis and management in a series of 11 patients

BACKGROUND/AIMS

VIPoma is a rare pancreatic endocrine tumor (PET) which secretes excessive amounts of VIP (Vasoactive Intestinal Peptide) that causes a special clinical syndrome characterized by secretory diarrhea, hypokalemia and achlorhydria. Among a total number of 76 patients (pts) with PETs, we present in this study 11 pts with VIPoma syndrome focusing on our diagnostic and therapeutic approach, in parallel with a brief review of the literature.

METHODOLOGY

Eleven pts (7 males and 4 females), aged from 2 to 83 years (mean age 53.1 years) were included. The diagnosis was based upon compatible clinical features and serum VIP values and was supported by the estimation of other peptides and neuroendocrine markers such as gastrin, pancreatic polypeptide and chromogranin-A (CgA). In 10/11 pts, diagnosis was confirmed histopathologically. The primary or metastatic lesions were located by conventional imaging methods or by OCTREOSCAN or Endoscopic Ultrasound (EUS). The follow-up period ranged from 2.5-13.5 years (mean 4.8 years).

RESULTS

Chronic secretory diarrhea, which persisted despite fasting, was the main symptom in all pts of our study. VIP levels at the time of diagnosis were more than 3 or 10 times the upper normal limit in 7/11 (63.6%) or 4/11 (36.4%) pts, respectively. The primary lesion was detected by CT scan or MRI in 6/11 (54.5%), with EUS or abdominal angiography in 4/11 (36.4%). OCTREOSCAN revealed a solitary lesion in the right hepatic lobe, not detected by all the previous studies, while it detected, as a whole, the primary lesion in 10/11 (91%), and the metastases in 3/4 (75%) pts. In 7/11 (63.6%) the primary lesion was located in the pancreas, whereas in the rest it was in the duodenum or retroperitoneum. A surgical resection was possible in 7/11 (63.6%) pts, while pts with metastatic disease already or poorly differentiated tumors also received additional treatment with somatostatin analogues and chemotherapy. Liver metastases and poor differentiation of tumors seemed to be negative prognostic factors.

CONCLUSIONS

Clinical suspicion, early diagnosis and precise management may affect survival and improve the quality of life of patients. Also, surgical treatment, as extensive as possible, in combination with somatostatin analogues or chemotherapy when necessary, may also result in prolonged survival, also in patients with advanced disease.

Abdominal rectus muscle sheath abscess after spontaneous vaginal delivery. A case report

Postpartum infections cause severe morbidity of the mother. Abdominal wound infection and abscess formation are common complications after cesarean delivery. We report a case with abscess formation inside the abdominal rectus muscle sheath after normal, spontaneous vaginal delivery. A 32-year-old woman, para 2, had a normal vaginal delivery at term. The second postpartum day she complained of lower abdominal pain and was unable to stand up or walk. The fourth day, cellulitis of the skin of the lower abdomen developed and was treated with broad-spectrum intravenous antibiotics. The seventh day the patient developed septic fever and an abdominal rectus muscle sheath abscess was diagnosed. The abscess was treated with incisions and evacuation and the patient was discharged the 12th postoperative day. The abscess in this case, as hematoma formation was not preceded, was referred to ascending contamination via the lymphatic vessels.

Fetal small bowel obstruction: report of two cases

Fetal small bowel obstruction is usually diagnosed by sonography in the late second or early third trimester. We report two such cases of different etiology: a case of meconium ileus due to cystic fibrosis and a case of intestinal atresia. The only sonographic finding that allowed differentiation between them was the echogenic bowel in the case of cystic fibrosis.

Congestive heart failure and VVI pacing mode: dynamic behavior of the dispersion of ventricular repolarization

Dynamic Behavior of the Dispersion of Ventricular Repolarization. The aim of this study was to evaluate the circadian variation in the spatial dispersion of ventricular repolarization in continuously paced patients with congestive heart failure (CHF). Fourteen patients (10 males, 4 females, aged 65 +/- 8 years) with CHF due to dilated cardiomyopathy (DCM) and an echocardiographic ejection fraction of 28% +/- 3% were studied. All patients underwent AV junctional RF ablation and permanent pacemaker implantation for drug refractory chronic atrial fibrillation (AF). Patients were evaluated at 1 month postimplant with a three-channel 24-hour Holter monitor, using the three plane Frank orthogonal leads (X, Y, and Z), in VVI pacing mode at 70 beats/min. For each hour, the mean value of spike-T interval dispersion of the first five beats was measured. The control group consisted of 20 patients without structural heart disease, but with AF and complete AV block, continuously paced in VVI mode at 70 beats/min. The dispersion of the spike-T interval had a circadian behavior in the study population, with higher values at night and lower during the daytime. During the daytime, the mean value of spike-T interval dispersion was 39 +/- 5 ms and during the nighttime it was 45 +/- 7 ms (P = 0.003). Such a difference between day and night was not found in the control group (38 +/- 6 ms and 40 +/- 8 ms, respectively, P = NS). In the daytime period the mean value of spike-T interval dispersion of our study population was comparable to that of the control group (P = NS), while during the nighttime it was significantly higher (P = 0.0004). In conclusion, by evaluating the dispersion of ventricular repolarization in two dimensions, space and time, a circadian variation was found in paced patients with CHF due to DCM. The increased QT dispersion in these patients during the nighttime period was attributed to different effects of vagal activity in normal and abnormal myocardial areas.

Effect of nifedipine on the sick sinus syndrome

The effect of nifedipine (N) on sinus node (SN) function was studied in 15 patients (9 males, 6 females) sixty-two to seventy-six (mean 68.1 +/- 11) years old, with sick sinus syndrome (SSS). SSS was characterized electrophysiologically by a prolonged corrected sinus node recovery time (CSNRT greater than 535 msec) and/or prolonged sinoatrial conduction time (SACT greater than 125 msec), assessed by applying premature atrial stimulation. Ten mg N was given sublingually, and CSNRT and SACT were again evaluated sixty minutes after N administration, and again ten minutes after 1.5 mg atropine (A) was given IV. Heart rate increased significantly after N (p less than 0.005), systolic blood pressure (SBP) diminished significantly (p less than 0.005), and CSNRT and SACT shortened significantly (p less than 0.005, p less than 0.005) and became normal in 7 and 5 patients respectively. After A administration, a further significant increase of heart rate (p less than 0.005) and decrease of CSNRT (p less than 0.005) and SACT (p less than 0.005) were observed. CSNRT and SACT became normal in 8 and 7 patients respectively. SBP remained stable.