Journal articles on the topic 'Functional murmur'

Pectus Excavatum (PE) is normally an isolated congenital disorder, but it can also occur with congenital heart defect (CHD). The surgical strategy has evolved over the last 20 years from staged repair to simultaneous repair of both defects. We present a case of using the Nuss procedure for PE during atrial septal defect (ASD) . A 29 year old male possess detectable systolic murmur along with exertional dyspnea, fatigue of NYHA Class -II functional status and PE. Correction of these morbidities, a surgery was conducted in the Cardiac Surgery Department in July 2017 in Bangladesh Specialized Hospital, Dhaka. Doing a full midline incision, ASD was repaired after Cardiopulmonary bypass was done. The PE correction was done simultaneously with ASD correction. After completion of chest closure, the left sided non-communicating hydrocele was operated on, and tunical sac was excised and averted. After convalescing uneventfully, the patient was discharged.This case shows that in carefully selected cases with concomitant PE and ASD, a combination of the Nuss procedure and ASD repair and also correction of hydrocele.
 CBMJ 2018 January: Vol. 07 No. 01 P: 35-39

Patent ductus arteriosus (PDA) is one of the most common congenital heart defects, accounting for 5%–10% of all congenital heart disease in term infants. The occurrence of PDA is inversely related to gestational age and weight, with an even greater incidence in preterm infants. The maintenance of ductal patency is essential for the normal development of the fetus. In the neonate, however, persistent patency of the ductus arteriosus (DA) is associated with significant morbidity and mortality. Normally, at birth, the DA constricts, resulting in intraluminal ischemic hypoxia, which eventually leads to closure and remodeling of the ductus. PDA in term infants is usually associated with a functional defect, whereas in preterm infants it is associated with immaturity. Normal physiologic mechanisms contributing to closure - oxygen tension and decreased prostaglandins—are altered in prematurity. Clinical signs of ductal patency include murmur, tachycardia, bounding peripheral pulses, and congestive heart failure and associated symptoms. Symptoms are not always present; therefore, diagnostic imaging is critical if a PDA is suspected on clinical grounds. Three management strategies are currently available for PDA: fluid restriction and diuretics (as clinically appropriate), medical intervention, and surgical ligation. Pharmacologic closure can be achieved via administration of intravenous indomethacin or ibuprofen lysine. While both agents have shown similar efficacy, ibuprofen lysine has demonstrated an improved safety profile, particularly in terms of renal effects, compared to indomethacin.

AbstractObjectiveBy means of retrospective analysis of our institutional experience, we reviewed the clinical manifestation and outcomes of patients subsequent to surgical repair of double-chambered right ventricle.MethodsBetween 1988 and 2005, we performed surgical repair in 35 of 37 patients diagnosed with double-chambered right ventricle. The patients ranged in age from 4 to 69 years, with a mean of 21.3 years. Most presented in infancy, with initial manifestation of a short systolic murmur in 34 (92%) of all cases. Pressure gradients were measured invasively across the right ventricular outflow tract of between 30 and 140 mmHg, with a median of 60 mmHg. An associated ventricular septal defect was present in 26 patients (70%). Of the group, 4 patients were aged over 40 years, and 2 had previously undergone operative closure of a ventricular septal defect.ResultsThe operative interval ranged from 2 months to 41 years, with a median of 9 years. In all, we resected muscular bundles and enlarged the right ventricular outflow tract. There was no hospital or late death. Median follow-up subsequent to surgery was 7 years, with a range from 0.4 to 11 years. No patient required further surgery to relieve any obstruction of the right ventricular outflow tract, nor long term medical therapy or pacing because of cardiac arrhythmia.ConclusionsSurgical repair of a double-chambered right ventricle yields excellent haemodynamic and functional results over the mid to long term.

Abstract Bicoronary - pulmonary artery fistulae are rare conditions. Their association with mitral valve prolapse is even rarer and randomly reported. This association is important to be recognized in clinical practice because of the differential diagnose problems. Closing the coronary fistulae and mitral valve replacement during the same surgical procedure is probably the optimal management of these patients. We report a case involving the correction of congenital bicoronarypulmonary artery fistulae and mitral valve replacement within the same surgical procedure in a 56 years old female patient with angina and clinical signs of left ventricular failure associating the fistulae to severe mitral regurgitation due to mitral valve prolapse. Past medical history revealed autoimmune thyroiditis, atrial fibrillation, mitral and tricuspid valve regurgitation. At admission physical examination revealed stable vital signs, irregular tachycardia with significant pulse and a mitral regurgitation systolic murmur. ECG showed atrial fibrillation, no ischemia. Echocardiography revealed severe mitral regurgitation, prolapse of anterior and posterior mitral leaflets, moderate tricuspid valve regurgitation, and mild pulmonary hypertension. Coronary angiogram showed no significant lesions of the epicardial vessels but high flow congenital bicoronary-pulmonary fistulae (right coronary artery and left coronary artery to main pulmonary artery). Surgical correction of the congenital bicoronarypulmonary fistulae was performed simultaneously with mitral valve replacement in the same session. Postsurgical evolution was uneventful. Post-procedural ECG showed atrial fibrillation with a controlled heart rate, postoperative echocardiography showed normal functional and normal positioned prosthetic mitral mechanical valve, and rather normal left ventricle function. Coexistence of bicoronary-pulmonary fistulae and mitral valve insufficiency due to prolapse in a symptomatic patient with angina pectoris is a very rare clinical entity. Solving both abnormalities within the same surgical procedure was the optimal management for this patient.

Background: Aortic stenosis refers to several types of anatomic and functional obstructions of the left ventricular outflow tract. In small animals, this anomaly is most commonly documented as either a congenital lesion or an obstruction that develops soon after birth. It is a hereditary disease, caused by a dominant autosomal gene and modifying genes that interfere with phenotype expression. Even though aortic thromboembolism may be a potential complication in cats with cardiac diseases, aortic stenosis is deemed rare in that species. In this paper, we report an unusual case of a Persian kitten with aortic stenosis that eventually developed arterial thromboembolism.Case: A 7-month-old Persian kitten (3.1 kg) was admitted to a Veterinary Teaching Hospital with a history of hindlimbs paralysis over the past 48 h, as well as excessive vocalization. Also, the cat presented with inappetence, adipsia, urine incontinence, and hematuria. On physical examination, we observed hypothermia and cold paws. The footpads were cyanotic and there were no palpable femoral pulses. Cardiac auscultation disclosed a regular fast pace (200 bpm) and a grade 2/6 murmur heard best over the left cardiac base, but irradiating to the contralateral hemithorax. Prothrombin time and activated partial thromboplastin time were within the normal reference range, but the complete blood count showed microcytosis, lymphopenia, and hyperproteinemia. Also, elevated alanine aminotransferase and BUN were identified. On the echocardiogram, we observed a subvalvular aortic stenosis, which resulted in concentric remodeling of the left ventricle and a mild left atrial dilation. The stenotic lesion was classified as mild. Also, the thoracic radiography unveiledcardiomegaly. The recommended therapy included atenolol (6.25 mg/cat PO, q24h), clopidogrel (18.7 mg/cat PO, q24h), enoxaparin (1 mg/kg SC, q24 h), methadone (0.2 mg/kg IM, q8h) and amoxicillin + potassium clavulanate (20 mg/kg SC, q12h). Additional recommendations included physical therapy on the hindlimbs as well as monitoring heart rate and blood pressure every two hours in the first day, and every six hours thereafter during hospitalization. Seven days later, the cat was depressed, extremely lethargic, and did not respond to therapy at all. Also, necrosis was documented on the hindlimb paws. Therefore, in face of the unfavorable prognosis, the owners opted for euthanasia.Discussion: Cats with cardiomyopathy have an increased risk for developing arterial thromboembolism. The dilated left atrium causes blood stasis and, because of the augmented sensitivity of platelets to serotonin, they aggregate and increase the likelihood of thrombi formation. While some thrombi remain within the heart, usually in the left atrial appendage, others may dislodge and follow blood flow to the aortic trifurcation down in the abdomen. That obstruction impairs blood flow to its tributaries such as the iliac and femoral arteries, which are involved with the hind limbs perfusion. Cats with severe stenotic lesions usually carry a bad prognosis, contrasting with our patient in which only a mild stenosis was documented.However, having developed aortic thromboembolism absolutely changed the prognosis for this cat. Although aortic stenosis is an uncommon condition in cats, its occurrence should be considered as differential diagnosis whenever young patients are admitted with a cardiac murmur. If the diagnosis is confirmed, the patient will need periodical re-evaluations due to the possibility of complications such as arterial thromboembolism. This condition carries a bad prognosis. In this case, it was responsible for the decline in clinical condition which eventually was crucial for the owner opting to euthanize the cat.Keywords: congenital heart disease, echocardiography, valve dysplasia, ischemia.

Background: High prevalence of Chronic heart failure due to Idiopathic Dilated Cardiomyopathy (DCM) is animportant cause of heart failure in Bangladesh. This study was carried out to find the clinical characteristics of thepatients with Idiopathic DCM, so that the data can be used to treat symptoms and improve survival and treatment.
 Methodology: This prospective observational study was carried out in the Department of Cardiology, BIRDEMGeneral Hospital, Dhaka, Bangladesh from January 2012 to December 2018. Total 50 consecutive admittedpatients fulfilling the criteria of Idiopathic DCM were studied. Clinical information, findings fromEchocardiography and other relevant investigations were collected for analysis.
 Results: Among total 50 patients, 30(60.0%) were male and 20(40.0%) were female. Majority 20(40.0%) patientsbelonged to age 51-60 years and their mean age was found 55.34±13.24 years. Using NYHA (New York HeartAssociation) functional status classification of the patients, 18(36.0%) patients were found in NYHA class I,15(30.0%) in class II, 12(24.0%) in class III and 5(10.0%)in class IV. Almost all patients presented with three basicsymptoms i.e. exertional dyspnea, easy fatigability and pedal edema. Orthopnea, Paroxosmal Nocturnal Dyspnoea(PND), palpitation & chest pain wewe also reported in almost half of the patients. Mean pulse was found88.78±15.75 beat/min, respiratory rate 20.79±6.48 breath/min, BMI 23.12±3.29 kg/m2, systolic BP 119.03±22.22mmHg and diastolic BP 75.00±12.54 mmHg. Bilateral basal crepitation 45(90.0%), Pedal edema 43(86.0%),Raised JVP 39(78.0%), Hepatomegaly 35(70.0%) were also found. Third heart sound in 34(68.0%), Pan systolicmurmur of Mitral regurgitation 40(80.0%), Pansystolic murmur of Tricuspid regurgitation was present in42(84.0%) among study patients. Mean left ventricular ejection fraction was found 30.44 ±4.91%, LVIDs 5.24±0.51cm and LVIDd 6.18 ±0.52 cm.
 Conclusion: Majority of the Idiopathic DCM patients belonged to age 51-60 year age group with malepredominance and clinical presentation was variable.
 Bangladesh Crit Care J September 2019; 7(2): 86-89

Abstract Abstract 5278 HIA due to ozone exposure on patients with glucose 6 phosphate dehydrogenase deficiency (G6PDd) is extremely rare. The purpose of this report is to describe in detail a case of HIA and DVT on a woman without G6PDd, with a successful treatment with fresh frozen plasma (FFP) transfusion and Thrombolysis. The patient is a 36 years old woman, that 3 months before she was diagnosed with multiple sclerosis (MS) because paresthesias in the fingers of her left foot and she received treatment with blood ozone exposure (at unknown dose) in 3 sessions each week for 3 months. The patient attended to our center with severe anemic syndrome during the last 2 weeks and disabling pain of her left leg of 12 hours of evolution. Physical examination showed pale ++++, jaundice ++, functional systolic murmur grade IV, without adenomegaly or splenomegaly, increasing volume, induration, erythema and intense pain from the ankle to the popliteal space of her left leg. The urine was dark. Laboratory data were haemoglobin 5 g/dL, hematocrit 17%, reticulocytes 62%, and platelets 281×109/L. Peripheral blood smear showed esquistocytes +++ and spherocytes ++, suggesting intravascular hemolysis. Total bilirrubin 2.99mg/dL, direct bilirubin 0.57, and LDH 750 U/L. Doppler ultrasound: obstruction of the deep and superficial venous system of tibial, peroneal and left popliteal veins. Four red cells units were transfused and FFP transfusion was started every 6 hours, anticoagulation with enoxaparina sodium (1mg/Kg/day) and thrombolysis with rhTPA 100 mg for 3 hours infusion. The patient successfully improved with increase and maintenance of hemoglobin, decrease of the reticulocytes count and evident clinical improvement of her left leg. She was in-hospital for 8 days at the end of which was achieved ambulation, Doppler showed remission of DVT. The association between exposure to ozone and HIA has not been informed in the absence of G6PD deficiency, and today, little is known of the ideal treatment. Though plasmapheresis is the treatment of choice in a HIA, the presence of DVT and be in a period appropriate for thrombolysis, determined the use of FFP transfusion as the main treatment. The right clinical evolution observed in the treatment of our patient gave her solving clinical problems. Ozone has been widely used for a variety of off-label purposes. In vitro experiments had demonstrated hemolysis with ozone concentration > 30 mcg/mL, therefore this case must represent an important alert for those ozone users, however the mechanism of hemolysis because ozone exposure remains to be elucidated. Disclosures: No relevant conflicts of interest to declare.

The paper presents the research results dissemination heart murmurs among sport horses and their impact on the performance of the animals. The studies were conducted on horses Ukrainian, Hanoverian and Westphalian warmblood and English thoroughbred breed used in classical equestrian sport.The clinical studies included measurements of body temperature, counting pulse rate and breathing, rate, cardiac shock, cardiac tones and murmurs. The criteria for evaluation of heart murmurs were: time of appearance, location, intensity, belonging to the cardiac phase (systole or diastole). Heart murmurs evaluated on a scale of 1 to 6. The studies were conducted at rest and not earlier than 2–hours after exercise.Heart sounds were recorded in 64% of sport horses, but most of them had no clinical significance since only 6.7% of the studied animals was reduced performance. Most recorded systolic murmurs (mitral valve – 20% of horses, tricuspid valve – 24%, pulmonary artery – 8%, aortic valve – 4% of the animals), rarely diastolic (aortic valve – 8% of horses).Our studies suggest that the prevalence of heart murmurs in sport horses depends on the age of the animals, exercise, functional and morphological changes valvular heart caused by constant exposure to sports training and more. However, to confirm these findings required further investigation.

AbstractTwo decades of evidence-based exploratory pursuits in heme-flavin enzymology led to the formulation of a new biological electron/moiety transfer paradigm, called murburn concept. Murburn is a novel literary abstraction from “mured burning” or “mild unrestricted burning”. This concept was invoked to explain the longstanding conundrum of maverick physiological dose responses and also applied to remodel the prevailing understanding of drug metabolism and cellular respiration. A conglomeration of simple ideas grounded in the known principles of thermodynamics and reaction chemistry, murburn concept invokes catalytic/functional roles for diffusible reactive species or radicals. Hitherto, diffusible reactive species were primarily seen as toxic agents of chaos, non-conducible to the maintenance of life-order. Since the murburn paradigm offers a distinctly different perspective for several biological phenomena, researchers holding conventional views of cellular metabolism pose a direct conflict of interests to the advancement of murburn concept. Murburn schemes are poised to integrate numerous metabolic motifs with holistic physiological outcomes; redefining pursuits in biology and medicine. To advance this agenda, I present a brief account of murburn concept and point out how redundant ideas are still advocated in some prestigious journals.

Although violent crime has declined in recent decades, it remains a recurring feature of daily life in some neighborhoods. Mounting evidence indicates that such violence has a long reach, which goes beyond family and friends of the victim and undermines the health of people in the surrounding community. However, like all forms of adversity, community violence elicits a heterogeneous response: Some remain healthy, but others deteriorate. Despite much scientific attention, the neural circuitries that contribute to differential adaptation remain poorly understood. Drawing on knowledge of the brain’s intrinsic functional architecture, we predicted that individual differences in resting-state connectivity would explain variability in the strength of the association between neighborhood violence and cardiometabolic health. We enrolled 218 urban youth (age 12–14 years, 66% female; 65% black or Latino) and used geocoding to characterize their exposure to neighborhood murder over the past five years. Multiple aspects of cardiometabolic health were assessed, including obesity, insulin resistance, and metabolic syndrome. Functional MRI was used to quantify the connectivity of major intrinsic networks. Consistent with predictions, resting-state connectivity within the central executive network (CEN) emerged as a moderator of adaptation. Across six distinct outcomes, a higher neighborhood murder rate was associated with greater cardiometabolic risk, but this relationship was apparent only among youth who displayed lower CEN resting-state connectivity. By contrast, there was little evidence of moderation by the anterior salience and default mode networks. These findings advance basic and applied knowledge about adaptation by highlighting intrinsic CEN connectivity as a potential neurobiological contributor to resilience.

Court discourse is a typical institutional discourse, recently arousing scholars’ interest. Systemic-functional approach provides an important perspective to investigate the court discourse, among which transitivity that involves the construal of experiential meaning is a significant tool in the analysis. However, it is still unknown how experiential meanings are construed through different process types in American courtroom discourse. Therefore, this paper will take the case of Jodi Arias’ murder as an example and investigate the courtroom discourse from the perspective of transitivity. In this study, two research questions will be focused on: (1) What is the distribution of six transitivity processes in the courtroom of Jodi Arias’ murder case? (2) What are the functions of six processes for each courtroom participant in the courtroom of Jodi Arias’ murder case? After the detailed analysis, two conclusions are reached: (1) The paper finds that the major processes in the courtroom is the material, mental, relational, and verbal process. The behavioural process and the existential process is least or none in the courtroom discourse. (2) Second, the processes have their own functions in the courtroom discourse. The findings can help improve people’s understanding of American courtroom discourse and enhance American courtroom communication.

This article uses religious coping theory to theorize about how and why race and ethnic groups on death row frame religious last statements at the moment of imminent death. Unique data (N = 269) drawn from death row inmates in Texas between December 1982 and April 2016 reveal uniformity in the dominance that black, white, and Hispanic inmates assign to relational forms of expressions that draw them closer to God and expressions that facilitate spiritual intimacy with others, over self-focused expressions that represent efforts to gain control over the imminent death experience or signal a transformed life. There is a hierarchy of preferred religious coping methods that changes for each group following the implementation of a new policy allowing the family and friends of murder victims (co-victims) to witness the execution of inmates. It is concluded that race and ethnic groups differ in the premium they place on preferred religious coping strategies when faced with imminent death, and a change in social context, such as the sudden presence of co-victims at executions, increases the religious content of last statements for all groups.

ABSTRACT Aim The aim of this work is to analyze by scanning electron microscopy implant components that have mechanically failed in vivo. Materials and methods Three clinical cases are presented relative to single lateral posterior restorations supported by implants and a case of a mandibular overdenture supported by two implants. In all the reported cases the presence of an incongruous occlusal load caused the fracture of the components of the implant supported restorations. Conclusion From the analysis of the cases examined in this study, it is deduced that the functional overload influences the biomechanical behavior of the prosthetic rehabilitation supported by an implant and may, in less fortunate cases, determine the failure following the fracture of the connecting screws and/or the fixture. How to cite this article Di Iorio D, Sinjari B, Feragalli B, Murmura G. Biomechanical Aspects In Late Implant Failures: Scanning Electron Microscopy Analysis of Four Clinical Cases. J Contemp Dent Pract 2011;12(5):356-360.

The research topic is based on the role of the job description in the current Iraqi Penal Code as an aggravating circumstance in the crime, and the legislator regulated it through the two cases: The first case: The perpetrator is an employee or entrusted with a public service in some crimes such as moral crimes, theft ... etc. The Iraqi legislator has tightened the penalty for these crimes when they are committed by those with a functional capacity, on the condition that they use their functional powers to carry out the crime, or that they exploit their position and job confidence in committing the crime. The second case: which is the fact that the victim is an employee or entrusted with a public service , such as crimes of assault, such as murder, abuse ... etc. In this case, the Iraqi legislator and some comparative legislation have tightened the punishment for these crimes when they occur on those with a functional capacity during or because of the performance of the job, and this is in order to provide adequate criminal protection for them to enable them to perform their job duties in the best way and away from fear, because they are exercising the job in the name of the state. The state must provide them with adequate protection.

In this critical essay, we respond to Lindebaum’s argument that neuroscientific methodologies and data have been accepted prematurely in proposing novel management theory. We acknowledge that building new management theories requires firm foundations. We also find his distinction between demand and supply-side forces helpful as an analytical framework identifying the momentum for the contemporary production of management theory. Nevertheless, some of the arguments Lindebaum puts forward, on closer inspection, can be contested, especially those related to the supply side of organizational cognitive neuroscience research: functional Magnetic Resonance Imaging (fMRI) data, motherhood statements and ethical concerns. We put forward a more positive case for organizational cognitive neuroscience methodologies and data, as well as clarifying exactly what organizational cognitive neuroscience really means, and its consequences for the development of strong management theory.

Background: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is rare. Unique anatomical characteristics observed include tethering secondary to the extensive collateral vessels, severe native coronary tortuosity, and massive dilation of the coronary arteries. This requires specific technical consideration to ensure safe translocation. Methods: A single-center retrospective review of six patients with ARCAPA was performed. Echocardiographic and computerized tomography scan data were analyzed for anatomical and functional cardiac characteristics. Operative techniques were analyzed, which reflected an evolution toward a modified-trapdoor technique. Results: Five children presented with asymptomatic murmurs and one adult patient with unstable angina. All patients underwent successful surgical correction. The modified trapdoor technique provided the most ideal geometry for coronary transfer secondary to its anatomical characteristics. Two patients had coronary button transfers above the sinotubular junction using vertical stab incisions, one had the button implanted after excising part of the aortic wall, and last three patients had modified trapdoor incisions. Mean cardiopulmonary bypass and cross-clamp times were 170 ± 27 minutes and 99.5 ± 29 minutes respectively. The average hospital stay was five days and there were no mortalities. Conclusions: Anomalous right coronary from the pulmonary artery’s unique anatomical characteristics require a coronary transfer technique different from that performed in aortic root replacement. In some respects, our modified technique resembles coronary transfers used in difficult arterial switch operations. The use of a modified trapdoor incision simplifies coronary transfer and may minimize coronary kinking and subsequent complications related to coronary transfer.

Patients with paranoia have always been a group of exiting but daunting patients for mental health professionals. Indeed, the risk of a violent acting out with important aggressive discharges confers to these patients an elevated dangerosity potential. If various criminological aspects of violence in paranoia have been described, their link to functional prognosis of patients have been seldom addressed.AimTo determine if criminological details of violence acts in paranoia patients predict their functional prognosis.MethodsA retrospective, descriptive and analytic study have been conducted, based on a chart consult. Twenty-three patients with paranoia (i.e. Chronic delusional disorder type jealousy or erotomania in DSM IV) patients have been included. These patients have been hospitalized in the forensic psychiatry department of Razi hospital of Tunis (Tunisia), between 1995 and 2015, after not being held by reason of insanity, according to article 38 of the Tunisian Criminal Code.ResultsDelusional disorder types were: jealousy (17), persecution (4), erotomania (1) and claim (1). The majority were married (18), undereducated (17), with irregular work (13). Forensic acts were uxoricide (15), attempted murder (5), violence against people (2) and destruction of public properties (1). Patients used bladed weapon in most of the cases (13), in the victim's residence (19), with premeditation in (17) of the crimes. Only 5 patients worked regularly after discharge.ConclusionIf our results expose further data concerning potential dangerosity of patients with delusional disorders, they also highlight the marginalized situation of these patients when released back into society.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Previous work suggests that explicit and implicit evaluations (good–bad) involve somewhat different neural circuits that process different dimensions such as valence, emotional intensity, and complexity. To better understand these differences, we used functional magnetic resonance imaging to identify brain regions that respond differentially to such dimensions depending on whether or not an explicit evaluation is required. Participants made either good–bad judgments (evaluative) or abstract–concrete judgments (not explicitly evaluative) about socially relevant concepts (e.g., “murder,” “happiness,” “abortion,” “welfare”). After scanning, participants rated the concepts for goodness, badness, emotional intensity, and how much they tried to control their evaluation of the concept. Amygdala activation correlated with emotional intensity and right insula activation correlated with valence in both tasks, indicating that these aspects of stimuli were processed by these areas regardless of intention. In contrast, for the explicitly evaluative good–bad task only, activity in the anterior cingulate, frontal pole, and lateral areas of the orbital frontal cortex correlated with ratings of control, which in turn were correlated with a measure of ambivalence. These results highlight that evaluations are the consequence of complex circuits that vary depending on task demands.

- In the well-known Lozano case, an Italian intelligence agent, Mr Nicola Calipari, remained killed in 2005 by an American soldier, Mr Mario Luis Lozano, while entering a US checkpoint on the way to the Baghdad airport soon after securing the release of an Italian journalist from Iraqi kidnappers. In the ensuing case, Italian courts addressed a number of sensitive questions, including that of jurisdiction over national troops involved, directly or indirectly, in so-called "humanitarian missions" abroad. Italian courts did have jurisdiction over the killing under Italian domestic law. Indeed, the murder of Mr Calipari can be regarded as a "political crime" under Article 8 of the Italian penal code. On such a premise, the question is whether Article 8 was superseded by a customary international law rule under Article 10 of the Italian Constitution aimed at excluding jurisdiction over Mr Lozano. State practice suggests that neither a customary rule on the exclusive jurisdiction of the sending State (as claimed by the Court of Assise of Rome in 2007) nor a customary rule on Mr Lozano's functional immunity (as claimed by the Court of Cassation in 2008) are established in customary international law. Rather, State practice reveals that a number of States are likely to recognize immunity from jurisdiction to the armed forces only in certain specific circumstances. Moreover, such immunity is quite different from the functional immunity traditionally enjoyed by diplomatic and consular agents, as well as from the immunities enjoyed by other high-ranking State officials, such as the Head of State, the Head of Government and the Minister for Foreign Affairs.

The paper discusses the characteristics of modern American presidential political rhetoric with special reference to Barack Obama’s speeches in which he addressed the highly publicized killings of black Americans. Three of the analysed speeches contain Obama’s rhetorical reaction to the judicial decisions not to indict the police officers responsible for the killings, while one speech gives his immediate reaction to the mass murder of black parishioners by a white supremacist. The study is based on the discourse-linguistic analysis of attitudinal meanings and their functions, which are conceptualized as evaluative frames. Evaluative frames are used to highlight different kinds of discourse participants through judgments of behaviour, attributions of emotions and evaluations of semiotic phenomena and objects. The theoretical framework for the different categories of evaluative frames is based on the theory of news framing and theory of evaluative language within systemic-functional linguistics. The findings of the analysis show that Obama uses an interplay of positive and negative evaluations of different kinds to transcend racial categorizations and avoid a direct attribution of blame. When he acknowledges the continuing relevance of the racial divide in US society, he often applies evaluative frames in such a way that they unify rather than divide the discourse participants on both sides of the divide.

Abstract A number of linguistic studies on courtroom discourse deal with witness examinations, however counsels’ opening statements have been given relatively little attention. Drawing on the analysis of a Crown Prosecutor’s opening statement in a murder trial held at the Supreme Court of New South Wales in Sydney, Australia, and using the Systemic Functional Linguistics framework (Halliday 1994), this study highlights the ways in which the prosecutor constructs his narrative of the crime in his opening statement in order to persuade the jurors of his views. Specifically, the analysis highlights the ways in which the narrative is made persuasive through its specific rhetorical organization and over-specification of orientational information, as well as more credible through quotations from participants with personal experience in the related events. It also shows the ways in which the prosecutor seeks to engage the jurors through his use of second-person pronouns, as well as his differentiated use of the crime participants’ names. Finally, this study highlights the dialogic and heteroglossic characteristics of the adversarial legal process, in that it both refers to what was previously stated and tries to anticipate the response of the jury, whose voice comes as the last word through their verdict.

Inter-floor noise is a severe social problem which causes illegal arson, violence, and even murder. In this paper, an inter-floor noise sensing system is proposed to detect and record information related to inter-floor noise in an apartment building. The proposed system measured the noise level and estimated the direction of the noise source along with the type of noise. The noise level measurement is based on the sound pressure level (SPL) measurement, which is a logarithmic measure of the effective pressure of a sound relative to a reference sound pressure. Noise source localization was performed using the estimated time difference of arrival (TDOA) from the microphone array. For the classification of noise types, the Mel frequency cepstral coefficients (MFCC) and zero-crossing rate (ZCR) were extracted from a noise signal, and the k-nearest neighbor algorithm was used to classify the type of noise. In addition, we developed a noise monitoring hardware to evaluate our methods in the actual environment. The experimental results demonstrated that the proposed system had a reliable accuracy for each functional unit. The results showed that the error of the noise level was approximately ±1.5 dB(A), the error of the direction estimation was approximately ±10°, and the accuracy of the classification for the noise type was more than 75%. These output data from the proposed system are expected to be used as important reference data for any dispute cases due to inter-floor noise.

The article examines the problems of the component s of the concept of threats to religious security, for example, which are transformed into concepts. Religion as a relatively independent socio-cultural reality needs protection from internal and external threats. Religious security is a system of conditions that ensures the preservation of the traditional religious system within the established norm that has historically developed. The problem of religious security was identified when the cases of anti-state, anti-social activities of religious associations became more frequent. Methodology: The following research methods were used to address the issues set in the article: general scientific methods – descriptive, systemic, structural-functional, comparative, institutional-comparative; general logical methods – empirical, statistical, prognostic modeling and analysis; special methods of political science. The preference was given to the method of political-system analysis, by which the common and distinctive characteristics of the basic components of soft power strategies were identified, reflecting existing political, public, information and other challenges for international relations and global development. Results. As societies develop from agrarian to industrial to knowledge-based, growing existential security tends to reduce the importance of religion in people's lives and people become less obedient to traditional religious leaders and institutions. Research of the problem by scientists. Religion is characterized by the historical predominance of Catholic Christianity (40 % of the world's Catholics in the region). Conclusions. Although some religious conservatives warn that the retreat from faith will lead to a collapse of social cohesion and public morality, the evidence doesn't support this claim. Surprising as it may seem, countries that are less religious actually tend to be less corrupt and have lower murder rates than religious ones.

Introduction: Prisoners are one of the most vulnerable groups for having high prevalence of mental illness. There is a dearth of major studies conducted amongst prisoners in Nepal. The basic objective of this study is to study prevalence and nature of psychiatric morbidity in prisoners attending general OPD of Central jail Hospital, Kathmandu.
 Material and Method: This was a descriptive, cross-sectional study carried out in prisoners attending OPD of central jail for a period of six months. Initial screening was done with self- reporting questionnaire (SRQ) and those having distress on SRQ were interviewed and diagnosis was made based on ICD-10 DCR and data analysis was done using SPSS version 16.
 Results: A total of 121 prisoners out of 300 prisoners attending OPD of central jail hospital during a period of six months had been diagnosed to suffer from psychiatric morbidity. Majority of cases were within age group 26-30 years (20.7%) with male preponderance (76.9%), married (69.4%), educated up to higher secondary level (38%), doing occupation as labor work (24%), Hindus (62.8%) with janajatis (32.2%), having low socioeconomic status (51.2%), belonging to joint family (50.4%) and were from rural areas (45.4%). Murder was the most common offence committed (33.9%) followed by drug trafficking (28.1%). Most common primary diagnosis belong to Neurotic, stress related and somatoform disorder (57%) followed by mood disorder (32.2%). Most common psychiatric morbidity among prisoners was generalized anxiety disorder (36.4%) followed by Moderate depressive episode (23.1%) and somatoform disorder (9.1%). The overall prevalence of psychiatric morbidity in prisoners attending OPD of central jail hospital was found to be 40.33%.
 Conclusion: A substantial burden of psychiatric morbidity exists in prison population of Nepal. Prompt recognition and treatment of mental illness in prison lead to decrease in functional disability and better quality of life.

Michele Stephen; Desire, divine and demonic; Balinese mysticism in the paintings of I Ketut Budiana and I Gusti Nyoman Mirdiana (Andrea Acri) John Lynch (ed.); Issues in Austronesian historical phonology (Alexander Adelaar) Alfred W. McCoy; The politics of heroin; CIA complicity in the global drug trade (Greg Bankoff) Anthony Reid; An Indonesian frontier; Acehnese and other histories of Sumatra (Timothy P. Barnard) John G. Butcher; The closing of the frontier; A history of the maritime fisheries of Southeast Asia c. 1850-2000 (Peter Boomgaard) Francis Loh Kok Wah, Joakim Öjendal (eds); Southeast Asian responses to globalization; Restructuring governance and deepening democracy (Alexander Claver) I Wayan Arka; Balinese morpho-syntax: a lexical-functional approach (Adrian Clynes) Zaharani Ahmad; The phonology-morphology interface in Malay; An optimality theoretic account (Abigail C. Cohn) Michael C. Ewing; Grammar and inference in conversation; Identifying clause structure in spoken Javanese (Aone van Engelenhoven) Helen Creese; Women of the kakawin world; Marriage and sexuality in the Indic courts of Java and Bali (Amrit Gomperts) Ming Govaars; Dutch colonial education; The Chinese experience in Indonesia, 1900-1942 (Kees Groeneboer) Ernst van Veen, Leonard Blussé (eds); Rivalry and conflict; European traders and Asian trading networks in the 16th and 17th centuries (Hans Hägerdal) Holger Jebens; Pathways to heaven; Contesting mainline and fundamentalist Christianity in Papua New Guinea (Menno Hekker) Ota Atsushi; Changes of regime and social dynamics in West Java; Society, state and the outer world of Banten, 1750-1830 (Mason C. Hoadley) Richard McMillan; The British occupation of Indonesia 1945-1946; Britain, the Netherlands and the Indonesian Revolution (Russell Jones) H.Th. Bussemaker; Bersiap! Opstand in het paradijs; De Bersiapperiode op Java en Sumatra 1945-1946 (Russell Jones) Michael Heppell; Limbang anak Melaka and Enyan anak Usen, Iban art; Sexual selection and severed heads: weaving, sculpture, tattooing and other arts of the Iban of Borneo (Viktor T. King) John Roosa; Pretext for mass murder; The September 30th Movement and Suharto’s coup d’état in Indonesia (Gerry van Klinken) Vladimir Braginsky; The heritage of traditional Malay literature; A historical survey of genres, writings and literary views (Dick van der Meij) Joel Robbins, Holly Wardlow (eds); The making of global and local modernities in Melanesia; Humiliation, transformation and the nature of cultural change (Toon van Meijl) Kwee Hui Kian; The political economy of Java’s northeast coast c. 1740-1800; Elite synergy (Luc Nagtegaal) Charles A. Coppel (ed.); Violent conflicts in Indonesia; Analysis, representation, resolution (Gerben Nooteboom) Tom Therik; Wehali: the female land; Traditions of a Timorese ritual centre (Dianne van Oosterhout) Patricio N. Abinales, Donna J. Amoroso; State and society in the Philippines (Portia L. Reyes) Han ten Brummelhuis; King of the waters; Homan van der Heide and the origin of modern irrigation in Siam (Jeroen Rikkerink) Hotze Lont; Juggling money; Financial self-help organizations and social security in Yogyakarta (Dirk Steinwand) Henk Maier; We are playing relatives; A survey of Malay writing (Maya Sutedja-Liem) Hjorleifur Jonsson; Mien relations; Mountain people and state control in Thailand (Nicholas Tapp) Lee Hock Guan (ed.); Civil society in Southeast Asia (Bryan S. Turner) Jan Mrázek; Phenomenology of a puppet theatre; Contemplations on the art of Javanese wayang kulit (Sarah Weiss) Janet Steele; Wars within; The story of Tempo, an independent magazine in Soeharto’s Indonesia (Robert Wessing) REVIEW ESSAY Sean Turnell; Burma today Kyaw Yin Hlaing, Robert Taylor, Tin Maung Maung Than (eds); Myanmar; Beyond politics to societal imperatives Monique Skidmore (ed.); Burma at the turn of the 21st century Mya Than; Myanmar in ASEAN In: Bijdragen tot de Taal-, Land- en Volkenkunde no. 163 (2007) no: 1, Leiden

<p><strong>List of Abstract Titles and authors:<br /></strong></p><p><strong>1. Psychosis: A matter of mental effort?</strong></p><p>M Borg, Y Y van der Zee, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>2.In search of an affordable, effective post-discharge intervention: A randomised control trial assessing the influence of a telephone-based intervention on readmissions for patients with severe mental illness in a developing country</strong></p><p><strong></strong>U A Botha, L Koen, M Mazinu, E Jordaan, D J H Niehaus</p><p><strong>3. The effect of early abstinence from long-term methamphetamine use on brain metabolism using 1H-magnetic resonance spectro-scopy (1H-MRS)</strong></p><p>A Burger, S Brooks, D J Stein, F M Howells</p><p><strong>4. The effect of <em>in utero exposure </em>to methamphetamine on brain metabolism in childhood using 1H-magnetic resonance spectroscopy (1H-MRS)</strong></p><p>A Burger, A Roos, M Kwiatkowski, D J Stein, K A Donald, F M Howells</p><p><strong>5. A prospective study of clinical, biological and functional aspects of outcome in first-episode psychosis: The EONKCS Study</strong></p><p><strong></strong>B Chiliza, L Asmal, R Emsley</p><p><strong>6. Stimulants as cognitive enhancers - perceptions v. evidence in a very real world</strong></p><p><strong></strong>H M Clark</p><p><strong>7. Pharmacogenomics in antipsychotic drugs</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>8. Serotonin in anxiety disorders and beyond</strong></p><p><strong></strong>Ilse du Plessis</p><p><strong>9. HIV infection results in ventral-striatal reward system hypo-activation during cue processing</strong></p><p><strong></strong>S du Plessis, M Vink, J A Joska, E Koutsilieri, A Bagadia, D J Stein, R Emsley</p><p><strong>10. Disease progression in schizophrenia: Is the illness or the treatment to blame?</strong></p><p>R Emsley, M J Sian</p><p><strong>11. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p> S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>12. Iron deficiency in two children diagnosed with multiple sclerosis: Report on whole exom sequencing</strong></p><p><strong></strong>S Janse van Rensburg, R van Toorn, J F Schoeman, A Peeters, L R Fisher, K Moremi, M J Kotze</p><p><strong>13. Benzodiazepines: Practical pharmacokinetics</strong></p><p><strong></strong>P Joubert</p><p><strong>14. What to consider when prescribing psychotropic medications</strong></p><p><strong></strong>G Lippi</p><p><strong>15. Current prescribing practices for obsessive-compulsive disorder in South Africa: Controversies and consensus</strong></p><p><strong></strong>C Lochner, L Taljaard, D J Stein</p><p><strong>16. Correlates of emotional and behavioural problems in children with preinatally acquired HIV in Cape Town, South Africa</strong></p><p><strong></strong>K-A Louw, N Phillips, JIpser, J Hoare</p><p><strong>17. The role of non-coding RNAs in fear extinction</strong></p><p><strong></strong>S Malan-Muller, L Fairbairn, W M U Daniels, M J S Dashti, E J Oakleley, M Altorfer, J Harvey, S Seedat, J Gamieldien, S M J Hemmings</p><p><strong>18. An analysis of the management og HIV-mental illness comorbidity at the psychiatric unit of the Dr George Mukhari Academic Hospital</strong></p><p><strong></strong>M L Maodi, S T Rataemane, T Kyaw</p><p><strong>19. The identification of novel genes in anxiety disorders: A gene X environment correlation and interaction study</strong></p><p><strong></strong>N W McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D J Stein, V Russel, C Lochner</p><p><strong>20. Collaborations between conventional medicine and traditional healers: Obstacles and possibilities</strong></p><p><strong></strong>G Nortje, S Seedat, O Gureje</p><p><strong>21. Thought disorder and form perception: Relationships with symptoms and cognitive function in first-episode schizophrenia</strong></p><p>M R Olivier, R Emsley</p><p><strong>22. Investigating the functional significance of genome-wide variants associated with antipsychotic treatment response</strong></p><p><strong></strong>E Ovenden, B Drogemoller, L van der Merwe, R Emsley, L Warnich</p><p><strong>23. The moral and bioethical determinants of "futility" in psychiatry</strong></p><p><strong></strong>W P Pienaar</p><p><strong>24. Single voxel proton magnetic resonance spectroscopy (1H-MRS) and volumetry of the amylgdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A T Hess, J Zwart, F Ahmed-Leitao, E Meintjies, S Seedat</p><p><strong>25. Schizoaffective disorder in an acute psychiatric unit: Profile of users and agreement with Operational Criteria (OPCRIT)</strong></p><p><strong></strong>R R Singh, U Subramaney</p><p><strong>26. The right to privacy and confidentiality: The ethics of expert diagnosis in the public media and the Oscar Pistorius trial</strong></p><p><strong></strong>C Smith</p><p><strong>27. A birth cohort study in South Africa: A psychiatric perspective</strong></p><p>D J Stein</p><p><strong>28. 'Womb Raiders': Women referred for observation in terms of the Criminal Procedures Act (CPA) charged with fetal abduction and murder</strong></p><p><strong></strong>U Subramaney</p><p><strong>29. Psycho-pharmacology of sleep wake disorders: An update</strong></p><p>R Sykes</p><p><strong>30. Refugee post-settlement in South Africa: Role of adjustment challenges and family in mental health outcomes</strong></p><p><strong></strong>L Thela, A Tomita, V Maharaj, M Mhlongo, K Jonathan</p><p><strong>31. Dstinguishing ADHD symptoms in psychotic disorders: A new insight in the adult ADHD questionnaire</strong></p><p>Y van der Zee, M Borg, J H Hsieh, H Temmingh, D J Stein, F M Howells</p><p><strong>32. Oscar Pistorius ethical dilemmas in a trial by media: Does this include psychiatric evaluation by media?</strong></p><p>M Vorster</p><p><strong>33. Genetic investigation of apetite aggression in South African former young offenders: The involvement of serotonin transporter gene</strong></p><p>K Xulu, J Somer, M Hinsberger, R Weierstall, T Elbert, S Seedat, S Hemmings</p><p><strong>34. Effects of HIV and childhood trauma on brain morphemtry and neurocognitive function</strong></p><p>G Spies, F Ahmed-Leitao, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>35. Measuring intentional behaviour normative data of a newly developed motor task battery</strong></p><p><strong></strong>S Bakelaar, J Blampain, S Seedat, J van Hoof, Y Delevoye-Turrel</p><p><strong>36. Resilience in social anxiety disorder and post-traumatic stress disorder in the context of childhood trauma</strong></p><p>M Bship, S Bakelaar, D Rosenstein, S Seedat</p><p><strong>37. The ethical dilemma of seclusion practices in psychiatry</strong></p><p>G Chiba, U Subramaney</p><p><strong>38. Physical activity and neurological soft signs in patients with schizophrenia</strong></p><p>O Esan, C Osunbote, I Oladele, S Fakunle, C Ehindero</p><p><strong>39. A retrospective study of completed suicides in the Nelson Mandela Bay Metropolitan Area from 2008 to 2013 - preliminary results</strong></p><p><strong></strong>C Grobler, J Strumpher, R Jacobs</p><p><strong>40. Serotonin transporter variants play a role in anxiety sensitivity in South African adolescents</strong></p><p><strong></strong>S M J Hemmings, L I Martin, L van der Merwe, R Benecke, K Domschke, S Seedat</p><p><strong>41. Investigation of variants within antipsychotic candidate pharmacogenes associated with treatment outcome</strong></p><p>F Higgins, B Drogmoller, G Wright, L van der Merwe, N McGregor, B Chiliza, L Asmal, L Koen, D Niehaus, R Emsley, L Warnich</p><p><strong>42. Effects of diet, smoking and alcohol consumption on disability (EDSS) in people diagnosed with multiple sclerosis</strong></p><p>S Janse van Rensburg, W Davis, D Geiger, F J Cronje, L Whati, M Kidd, M J Kotze</p><p><strong>43. The clinical utility of neuroimaging in an acute adolescnet psychiatric inpatient population</strong></p><p><strong></strong>Z Khan, A Lachman, J Harvey</p><p><strong>44. Relationships between childhood trauma (CT) and premorbid adjustment (PA) in a highly traumatised sample of patients with first-episode schizophrenia (FES</strong>)</p><p>S Kilian, J Burns, S Seedat, L Asmal, B Chiliza, S du Plessis, R Olivier, R Emsley</p><p><strong>45. Functional and cognitive outcomes using an mTOR inhibitor in an adolescent with TSC</strong></p><p>A Lachman, C van der Merwe, P Boyes, P de Vries</p><p><strong>46. Perceptions about adolescent body image and eating behaviour</strong></p><p><strong></strong>K Laxton, A B R Janse van Rensburg</p><p><strong>47. Clinical relevance of FTO rs9939609 as a determinant of cardio-metabolic risk in South African patients with major depressive disorder</strong></p><p>H K Luckhoff, M J Kotze</p><p><strong>48. Childhood abuse and neglect as predictors of deficits in verbal auditory memory in non-clinical adolescents with low anxiety proneness</strong></p><p>L Martin, K Martin, S Seedat</p><p><strong>49. The changes of pro-inflammatory cytokines in a prenatally stressed febrile seizure animal model and whether <em>Rhus chirindensis</em> may attenuate these changes</strong></p><p><strong></strong>A Mohamed, M V Mabandla, L Qulu</p><p><strong>50. Influence of TMPRSS6 A736v and HFE C282y on serum iron parameters and age of onset in patients with multiple sclerosis</strong></p><p><strong></strong>K E Moremi, M J Kotze, H K Luckhoff, L R Fisher, M Kidd, R van Toorn, S Janse van Rensburg</p><p><strong>51. Polypharmacy in pregnant women with serious mental illness</strong></p><p>E Thomas, E du Toit, L Koen, D Niehaus</p><p><strong>52. Infant attachment and maternal depression as predictors of neurodevelopmental and behavioural outcomes at follow-up</strong></p><p>J Nothling, B Laughton, S Seedat</p><p><strong>53. Differences in abuse, neglect and exposure to community violence in adolescents with and without PTSD</strong></p><p><strong></strong>J Nothling, S Suliman, L Martin, C Simmons, S Seedat</p><p><strong>54. Assessment of oxidative stress markers in children with autistic spectrum disorders in Lagos, Nigeria</strong></p><p><strong></strong>Y Oshodi, O Ojewunmi, T A Oshodi, T Ijarogbe, O F Aina, J Okpuzor, O C F E A Lesi</p><p><strong>55. Change in diagnosis and management of 'gender identity disorder' in pre-adolescent children</strong></p><p>S Pickstone-Taylor</p><p><strong>56. Brain network connectivity in women exposed to intimate partner violence</strong></p><p>A Roos, J-P Fouche, B Vythilingum, D J Stein</p><p><strong>57. Prolonged exposure treatment for PTSD in a Third-World, task-shifting, community-based environment</strong></p><p>J Rossouw, E Yadin, I Mbanga, T Jacobs, W Rossouw, D Alexander, S Seedat</p><p><strong>58. Contrasting effects of early0life stress on mitochondrial energy-related proteins in striatum and hippocampus of a rat model of attention-deficit/ hyperactivity disorder</strong></p><p><strong></strong>V Russell, J Dimatelis, J Womersley, T-L Sterley</p><p><strong>59. Attention-deficit hyperactivity disorder in adults: A South African perspective</strong></p><p>R Schoeman, M de Klerk, M Kidd</p><p><strong>60. Cognitive function in women with HIV infection and early-life stress</strong></p><p>G Spies, C Fennema-Notestine, M Cherner, S Seedat</p><p><strong>61. Changes in functional connectivity networks in bipolar disorder patients after mindfulness-based cognitic therapy</strong></p><p>J A Starke, C F Beckmann, N Horn</p><p><strong>62. Post-traumatic stress disorder, overweight and obesity: A systematic review and meta-analysis</strong></p><p><strong></strong>S Suliman, L Anthonissen, J Carr, S du Plessis, R Emsley, S M J Hemmings, C Lochner, N McGregor L van den Heuvel, S Seedat</p><p><strong>63. The brain and behaviour in a third-trimester equivalent animal model of fetal alcohol spectrum disorders</strong></p><p>P C Swart, C B Currin, J J Dimatelis, V A Russell</p><p><strong>64. Irritability Assessment Model (IAM) to monitor irritability in child and adolescent psychiatric disorders.</strong></p><p>D van der Westhuizen</p><p><strong>65. Outcome of parent-adolescent training in chilhood victimisation: Adaptive functioning, psychosocial and physiological variables</strong></p><p>D van der Westhuizen</p><p><strong>66. The effect of ketamine in the Wistar-Kyoto and Sprague Dawley rat models of depression</strong></p><p>P J van Zyl, J J Dimatelis, V A Russell</p><p><strong>67. Investigating COMT variants in anxiety sensitivity in South African adolescents</strong></p><p>L J Zass, L Martin, S Seedat, S M J Hemmings</p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p><strong><br /></strong></p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p><p> </p>

Theoretically, the Byzantine Emperor was, just like in the times of the Roman Empire, chosen on the basis of his personal qualities and merits ? by the grace of God, of course. Practically, the factors which determined the ascension of a person to the throne were much more complex, the methods of gaining power being multifarious. In consequence, the political philosophy was confronted with the question of whether it is virtue (aret?) or origin (g?noz) that defines an Emperor. Independently of this rather theoretical question, however, and despite the claims that the personal qualities are decisive in the choice of the Emperor, the origin of the ruler played an important role in the consciousness of the Byzantines of all epochs. This is why great attention was paid to the creation of family trees, especially in the cases when the Emperor was of low origin (homo novus) or when it was for some reason necessary to strengthen his legitimacy. The choice of the genealogy was not random: since it carried a clear political message, it was of utmost importance with whom the Emperor in power would be associated and whose historical deeds or legendary personality would serve as a moral model. Also important is the fact that the search of a "good family" was as a rule triggered by the need to confirm one's own virtue. Thus, genealogies often reflect a certain system of values, usually emphasizing morality, courage in war, care for the welfare of the country, piety, etc. The choice of the archetype depended, of course, on the needs of the ruler for whom the genealogy was created. All this allows us to consider legendary genealogies as an expression of the imperial ideology. Notwithstanding their chronological diversity, the Byzantine imperial genealogies display very similar characteristics, i.e. they contain stereotypical elements, many of which had been established already in the first centuries of the Eastern Empire. In the early Byzantine period, when Christianity was still young, Emperors were frequently associated with pagan gods and semi gods, like Jupiter, Mars or Hercules. The Roman tradition of the eastern part of the Empire is also reflected in the fictive genealogies, so that the Emperors often chose Western Emperors or illustrious personalities and families of the Republican Era as their ancestors. The convention of establishing genealogical relations with the past rulers or their families (e.g. Claudius Gothicus, Trajan, the Flavii) served on one hand to create the impression of continuity and legitimacy, and on the other, to affirm the proclaimed system of values, since individual Roman Emperors had by that time become the prototypes of certain values (so Nerva stood for tranquility, Titus for philanthropy, Antoninus for high morality, Hadrian for justice and legality, Trajan for a successful military leader). In the same fashion, the creation of the family ties with persons from the Roman republican past, like the members of the family of the Scipios or Gnaeus Pompeius, was instrumental in the emphasizing of not only noble origin but also virtue. Interestingly enough, whereas the bonds with the Roman state are permanently evoked, the exempla from the Greek history play only a minor role in legendary genealogies (mostly Corinthians and Spartans, sometimes even mythical nations, like Homer's Pheacians). The central position of the Roman ideology is also reflected in the tendency to establish direct geographical connections between the origin of the ruler and either Rome itself or one of the Western provinces, so that the motif of migration is often found in the genealogies. On the other hand, Byzantine writers sometimes tended to boast with their knowledge of the history of the Ancient Orient, connecting famous personalities (like Artaxerxes) or dynasties (Achaemenids, Arsacids) with the Emperor whose genealogy they were composing. A special place in legendary genealogies is occupied by Constantine the Great. Almost as a rule, the genealogies postulate a kinship with him, often confirming it with the alleged physical resemblance. Depending on the purpose of the genealogy, certain purported features of Constantine's character were emphasized, so that he is alternately mentioned as a protector of the Christian faith, a triumphant military leader, or as a wise administrator of the Empire. Apart from that, the motifs of founding the new Capital and the migration of the Roman patrician families to Constantinople represent important topoi in this literary genre. The two most fascinating specimens of legendary genealogies in the Byzantine literature ? those of Basil I the Macedonian and Nikephoros III Botaneiates ? show that the choice of the elements of which the genealogy is composed (personality, family, dynasty) is at the same time a strong indication of the reason why it was composed in the first place. The genealogy of Basil the Macedonian was doubtlessly conceived by more than one person. It is quite certain that the idea to compose it originally came from Photios and was taken over by Basil's descendents ? his son Leo VI and his grandson Constantine VII Porphyrogennetos. The core of Basil's legendary genealogy is the story of his origin from the Parthian-Armenian dynasty of Arsacids (an indication of the Armenian origin of the founder of the Macedonian dynasty?). Constantine Porphyrogennetos elaborated this story further, describing in some detail the fate of Arsac's descendents, to whom Basil was allegedly related on his father's side, in the Byzantine Empire. This, of course, does not mean that he forgot to create connections between his grandfather and the standard legendary ancestors, like Constantine the Great (on Basil's mother's side) and Alexander the Great (the common ancestors of both Basil's parents). This apocryphal family tree certainly has its roots in the fact that the founder of the Macedonian dynasty was a parvenu of low origin, whose ascent to the throne was maculated by the murder of his predecessor and benefactor Michael III: apart from providing Basil with the noble origin, the genealogy was supposed to strengthen his right to the crown. One should keep in mind, though, that Basil's genealogy was written in the time of "Macedonian renaissance", so that its content is doubtlessly partly a product of the erudition of the compilers. In the course of time, legendary genealogies were enriched with new elements, stemming from the Byzantine history in the narrower sense of the word. The genealogy of Nikephoros III Botaneiates, compiled by Michael Attaleiates in the second half of the 11th century, is a good illustration to this. In contrast to Basil the Macedonian's genealogy, it is interwoven with real historical data, so that it cannot be called 'legendary' in its entirety. It would probably be more appropriate to call it a genealogy of both the Phokades and the Botaneiatai, since its core is made up of an invented story of the origin of the famous Byzantine family of Phokades, from which the family of Botaneiatai purportedly stems. The genealogy is clearly divided into three parts. In the first part, Attaleiates develops a theory according to which the Phokades are descendents of the Roman patrician families of Fabii and Scipios. The second part is devoted to the elaboration of the genealogical connection between the Phokades and the Botaneiatai, a tour deforce achieved by the claim that the latter are direct descendents of Nikephoros II Phokas, who is not only the central figure of this part in his capacity as an ancestor of Nikephoros III, but also as a model of a virtuous Emperor. Comparable to the habit of other writers to single out one or another characteristic trait of Constantine the Great according to their needs, Attaleiates concentrates on Nikephoros Phokas' military qualities, which are similar to those possessed by his "descendent" Botaneiates, and emphasizes the physical resemblance between the two rulers. In all likelihood, the part on the genealogy of the Phokades, as well as the story of Nikephoros Phokas, were taken over from an earlier tradition dealing with this renowned family, which Attaleiates implicitly mentions when he says that he had used 'an old book' and some other writings. As indicated above, the last, third, part of the genealogy, devoted to the deeds of Nikephoros Botaneiates' father and grandfather, does not fit the narrow definition of a legendary genealogy, despite the exaggerations Attaleiates uses in order to satisfy the demands of the genre. The description of Nikephoros Botaneiates' family tree represents merely an excursus within Attaleiates' History, but its composition has nevertheless an internal coherence and logic. Namely, all parts of the genealogy (the histories of the Fabii/Scipios, Phokades, and Botaneiatai) have one characteristic in common: the stories of the military deeds of the members of these families are used as an illustration of the military virtues of Nikephoros III. Since the hidden intention of the panegyric for Nikephoros III Botaneiates is to justify his usurpation of the throne, it is clear that a genealogy in this form ? especially the section pertaining to Nikephoros Phokas and his kinship with the usurper's father and grandfather ? represents a good basis for a legalistic interpretation of the coup d'?tat of 1078. The permeation of legendary genealogies with the Byzantine history is not confined only to individual Emperors which, like Nikephoros II Phokas, get assigned the role of the ancestor and moral model: some aristocratic families, most often the Phokades and the Doukai, also became moral exempla, serving to prove the reputation and the nobility of the ruler. As in the case of the Phokades, there is also a legendary tradition surrounding the family of Doukai, which made them a kind of model family: Being related to them became a measure of nobility, since it allowed the less prominent families to occupy a more distinguished place on the hierarchy of the Byzantine nobility. The prominence certain family names achieved ? mostly those of the families which created a dynasty ? led from the beginning of the 12th century until the fall of the Empire to free adoption and combination of more different surnames (mostly Doukai, Komnenoi, Angeloi, Palaiologoi, Kantakouzenoi, etc.). This, in turn, led to the creation of fictitious family trees. This kind of apocryphal construction of one's own origin was characteristic not only of the Byzantine culture but rather represented a very common phenomenon in the medieval world. In the medieval Serbia, for instance, its dissemination was fostered by the translation of the writings of the Byzantine chroniclers (Georgios Monachos, John Malalas, Constantine Manasses, and John Zonaras), so that legendary genealogies, written according to the Byzantine pattern, became an expression of the wish to include one's own history into the flow of the world history. Finally, a note on the reception of this genealogical line of thought. Parallel to the fictitious genealogies, there also existed a consciousness about them: Just like the development and the functional load of genealogies reveals a lot about the attitudes of the Byzantines towards power, so do the Byzantine writers who often criticize and ridicule the genealogies of individual Emperors. .

Abstract A 32 years old male without a history of cardiac disease or surgery was referred to our hospital due to abnormal findings on electrocardiography (ECG). He was a healthy active young man applying for private health insurance and did not have any symptoms. On physical examination he had normal vital signs and a systolic ejection murmur was present in the pulmonic area. His Oxygen saturation was 93% and had a functional capacity of 11 METs. On electrocardiography which is shown in part A and B of the figure, he had right axis deviation and poor R progression. On chest x-ray (part C of the figure) he had top normal cardiothoracic ratio and prominent main pulmonary artery (PA). On laboratory data he had normal complete blood count and normal electrolytes. Because of the murmur found in physical examination and the right axis deviation in ECG, transthoracic echocardiography was done for the patient which revealed single ventricle with left ventricle morphology and mild systolic dysfunction (part D of the figure). Abdominal and atrial situs were solitus. There was normal inferior vena cava continuity into the right atrium. Transesophageal echocardiography was also done for the patient which revealed thickening of the pulmonary valve and presence of a subvalvular web which resulted in severe subvalvular PS (part E and F of the figure). There were dilated main PA and its branches. The left sided atrioventricular valve had mild regurgitation while the right sided one had mild to moderate regurgitation. There was dilated coronary sinus due to persistent left superior vena cava. The case describes the role of echocardiography in diagnosing rare congenital heart disease in a patient without symptoms of cardiac disease. Abstract P1493 Figure

Abstract Introduction Double outlet right ventricle is a rare cause of acute cerebrovascular disease among young adults. Case. We report a case of a 21 year old male who presented with aphasia and left sided weakness. This was associated with cyanosis, easy fatigablity, recurrent epistaxis and loss of consciousness since childhood. On admission, patient’s vital sign was stable at 100/60, 90 bpm regular, 20 cycles per minute afebrile 80% oxygen saturation on room air. Patient is conscious, aphasic but follows simple commands. He had central cyanosis, clubbing of the upper and lower extremities, adynamic precordium, single s2, right ventricular heave, grade 3/6 systolic ejection murmur at the 2nd left intercoastal space parasternal line, 4/6 holosystolic murmur at the 4th intercoastal space parasternal line, and clear breath sounds. Neurologic examination revealed a 0/5 motor response on both left upper and lower extremity. Cranial MRI showed acute ischemic infarcts at the right frontal centrum semiovale and left cerebral hemisphere. During his admission, cardiac work up was done to investigate cardioembolic cause of the acute cerebrovascular disease. Transesophageal echocardiogram revealed congenital heart disease situs solitus with atrioventricular discordance; double outlet right ventricle, pulmonic valve stenosis, interatrial septal aneurysm with atrial septal defect and persistent left superior vena cava syndrome. During his hospital course, patient was started on aspirin, citicholine and atorvastatin for his cerebrovascular disease which was noted to improve after 2 days. Patient was also referred to the thoracovascular surgery team for comanagement who did modified Blalock Tausig shunting. Patient was referred to cardiac rehabilitation post procedure. His vital signs remained to be stable, his oxygen saturation increased to 90% at room air, and his functional capacity improved. Patient was discharged stable. Discussion Double outlet right ventricle is a rare complex congenital heart disease characterized by a conotruncal malseptation from which more than or equal to 50% of each great artery arises from the morphologic right ventricle. Associated defects like atrial septal defect and persistent left superior vena cava were reported in some literature. Cerebrovascular infarcts in complex cyanotic congenital heart disease might be secondary to polycythemia and/or paradoxical emboli bypassing the interatrial defect. Prompt prophylaxis such as periodic phlebotomy and/or anticoagulation in patients high risk for deep vein thrombosis must be evaluated for each patient.

AbstractFocused cardiac ultrasound (FoCUS)—a simplified, qualitative version of echocardiography—is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20–30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

Abstract Introduction Infective Endocarditis is a complex entity with great variability of clinical manifestations and a broad spectrum of complications. The prognosis depends not only on the baseline characteristics of the patient, but also on the agent and the complications, both local and systemic, with clinical repercussion. Two clinical cases are presented. A 67-year-old woman with history of uncharacterized aortic valve disease, presented in the emergency department with a 3-month evolution of asthenia and anorexia, and ocasional fever. She presented pallor, with a systolic murmur II/VI audible throughout the precordium and no other abnormalities in physical examination. Blood tests showed Hb 9g/dL with normal MCV and MCH, no leucocytosis, CRP 132mg/L, mild elevation of troponin I (0.32ng/ml; N <0.04ng / ml) and erythrocyturia. Transthoracic and transesophageal echocardiograms (TTE and TEE) showed a mass on the aortic valve suggestive of vegetation, conditioning a moderate aortic regurgitation (AoR) and mitroaortic pseudoaneurysm. Another 49-year-old female patient, submitted during childhood to a subaortic aneurysm, intraventricular comunication, AoR and aortic coarctation repair, presented with deterioration of functional and neurological status, associated with fever and lower limb edema. At examination she had tachypnea, tachycardia, pallor, aortic systolic murmur and signs of pulmonary congestion. Blood tests had leukocytosis and neutrophilia, CRP 174mg/L, Hb 9.6g/dL, elevation of liver enzymes, spontaneous INR 1.4 and no renal damage. TTE and TEE showed a mobile vegetation attached to the ventricular face of the aortic valve with major AoR and perivalvular abscess fistulized to the left ventricle. Both patients were treated with empirical therapy with gentamicin, ampicillin, and flucloxacillin. The first case evolved with hemodynamic stability, without heart failure or distant embolization. It was isolated a multisensitive Strept. gordonii and antibiotic therapy was de-escalated to ampicillin alone. In the second case, the patient showed rapidly progressive clinical deterioration with hypoxemic respiratory failure and cardiogenic shock requiring vasopressor support, and was urgently presented to a surgical center. No microorganism was isolated and broad-spectrum antibiotic therapy was maintained. She eventually died before she underwent valve surgery. On the other hand, in the first case, 6 weeks of antibiotic therapy were completed and aortic valve replacement surgery was performed without complications. She was discharged without cardiovascular symptoms and has an unremarkable follow-up of 6 months. With these cases it was possible to demonstrate the variability of presentations and prognosis of the same entity, even if ab initio with equally severe local complications. The initial stratification of the prognosis, the initiation of early treatment and the adequacy of the surgical time for intervention are of importance. Abstract P1301 Figure. Imaging study of endocarditis

Background: Hypothyroidism is an endocrine disease that leads to a reduction in the hormones thyroxine (T3) and triiodothyronine (T4), which therapy with levothyroxine restores the clinical signs related to the metabolic rate. Due to the influence of thyroid hormones on the heart, which is under the constant influence of the autonomic nervous system (ANS), dogs with hypothyroidism can develop bradycardia, arrhythmia, and dysautonomia. Heart rate variability (HRV) assesses autonomic modulation by the Holter method, which is scarce in dogs. We aimed to report the cardiac and autonomic effects of the primary hypothyroidism untreated and treated with levothyroxine in a canine case by Holter monitoring.Case: A 7-year-old female Dalmatian, weighing 36 kg, was referred for clinical evaluation due to apathy, weight gain, low hair quality, and lethargy. On physical examination, alopecic lesions on the hind limbs and tail, as well as bradycardia with a heart rate (HR) of 40-50 beats per minute (bpm) were observed, in addition to a 3/6 mitral murmur and 2/6 tricuspid murmur. Given the suspicion of thyroid gland disorder, the blood hormonal measurement revealed an increase in thyroid-stimulating hormone (TSH; 0.65 ng/mL) and a decrease in free T4 (0.11 ng/mL) and total T4 (0.44 ng/mL), confirming primary hypothyroidism. Therapy was started with a minimum dose of levothyroxine (0.913 mg, every 12 h), which clinical signs were restored in five months of treatment, with weight loss, hair growth, and active behavior. To assess the impact of untreated and treated hypothyroidism on the patient’s ANS, a Holter monitoring exam was performed for 24 h before and after therapy. Before treatment, the average HR was 75 bpm, and the HR<50 bpm occurred during 05 h 20 min 36 s. Still, 320 pause events (>2.0s), 1st-degree atrioventricular blocks (AVB), six ventricular ectopias events, and 2nd-degree sinoatrial block (SAB) were also observed. The ANS parasympathetic tone was significantly stimulated, highlighting bradycardia, arrhythmia, and dysautonomia. After five months of treatment with levothyroxine, the average HR was 89 bpm, and the HR<50 bpm occurred during 02 h 06 min 13 s. No ventricular pauses, blocks, or ectopias were observed, showing the stimulation of sympathetic tonus, which restored HR and ANS balance. Still, it was observed that the minimum levothyroxine dose corrected cardiac changes by increasing the low frequency (LF), decreasing the high frequency (HF), and, consequently, increasing the LF/HF ratio, normalizing the frequency conditions in HRV.Discussion: In the frequency index, HF indicates the vagal activity, whereas LF indicates both systems with parasympathetic predominance. Before treatment, the dog had a low LF/HF ratio (0.46), indicating dysautonomia with parasympathetic stimulation. After therapy, the conditions of bradycardia and functional cardiac capacity were corrected, restoring ANS, due to the serum recovery of thyroid hormones. This study reported the cardiac and autonomic effects of primary hypothyroidism untreated and treated with levothyroxine on a dog, that had intense bradycardia and abnormal stimulation of the parasympathetic tone, associated with episodes of 1st-degree AVB, ventricular ectopias, and 2nd-degree SAB. After therapy with a minimum dose of levothyroxine, there was a decrease in parasympathetic activity and an increase in sympathetic stimulus, correcting cardiac changes, and restoring the balance of ANS. As it is a simple, non-invasive, and safe tool that helps the clinician to understand cardiac autonomic modulation, it is recommended to adopt the Holter monitoring exam in cases of hypothyroidism cases to assess sympathetic-vagal balance and check potential cardiac risks.

Introduction: Rheumatoid arthritis (RA) can affect the heart via either inflammatory or ischemic processes. Pericardial disease is common in RA patients (30-50%) but is usually subclinical and not hemodynamically significant unless accompanied by infiltrative cardiomyopathy which carries a poor prognosis. Case report: A 65 year-old Caucasian male presented with long standing RA, severe fatigue and mild arthritis of MCP joints. Physical examination indicated S3, II/VI decrescendo diastolic murmur, and 2+ LL edema. ESR was normal but anti-CCP antibodies were > 250 units. On echocardiogram, a large pericardial mass was detected without atrial nor ventricular collapse and mild-moderate aortic regurgitation. Cardiac MRI defined the mass as a heterogeneous entity attached to the right, anterior, and inferior borders of the heart with compression of the right atrium, left and right ventricles, and the tricuspid valve. CT guided biopsy demonstrated fibrinous material without granulomas nor infection. Fatigue was initially attributed to uncontrolled RA and low dose prednisone and Leflunamide were started. 3 months later, he developed frank heart failure with NYHA class IIIb functional impairment. Cardiac Tamponade was confirmed by heart catheterization demonstrating typical 4-chamber pressure equalization. The mass was surgically excised with partial pericardiectomy. The patient had a dramatic improvement and 4 years later, he remains asymptomatic. Discussion: Our patient presented with uncontrolled RA and a pericardial mass that was not hemodynamically significant per the initial echocardiogram. Despite intensifying immunosuppression, his fatigue progressed with signs of congestive heart failure. Tamponade physiology was diagnosed invasively and the mass was resected with excellent recovery. Microscopically, the lesion consisted of a fibrous and exudative material. The patient likely had multiple asymptomatic episodes of pericarditis, gradually leading to this condition. We demonstrate with this case that RA pericardial disease can cause hemodynamic compromise while sparing myocardium and valves and that surgery is associated with very good prognosis. Physicians should be vigilant about a cardiac cause of fatigue in RA patients.

Abstract Introduction The objective of this case is to present a novel approach in percutaneous treatment of complex valvular heart disease in patient disqualified from cardiac surgery. Case Description A 59 year-old-man with a history coronary heart disease, myocardial infarctions (in 1993, 2011), percutaneous right coronary angioplasty (2011,2012), chronic kidney disease, persistent atrial flutter, Hodgkin"s lymphoma treated with radiotherapy and chemotherapy, was admitted to hospital due to congestive heart failure in NYHA class IV, despite optimal, maximal tolerated pharmacological treatment (furosemide 40 mg tid, torasemide 20 mg qd, bisoprolol 5 mg qd, perindopril 5 mg qd, spironolactone 25 mg qd, acetylsalicylic acid 75 mg qd, atorvastatin 40 mg qd) Physical examination showed BMI tachycardia 110/sec, blood pressure 95/68 mmHG, systolic murmur grade 5/6 best heard at the apex, moderate leg oedema. Chest auscultation revealed crepitations. Echocardiography revealed severe, functional mitral (MR) - 4+(VC 8/20 mm) and tricuspid (TR) regurgitation (4+); combined aortic valve disease (moderate stenosis (SA), mild regurgitation (AR) - SA max. grad. 39/23mmHg, valve area -1.3-1.4 cm2, LV end diastolic diameter (LVEDD)/LV end-systolic diameter (LVESD) 57/44 mm, LV ejection fraction 48%, both atrium enlargement (left atrium 38 cm2, right atrium 35 cm2). Angiography didn`t show significant changes in coronary arteries. Because of high surgical risk (Euroscore II 9,14%, STS 7,29%) and porcelain aorta confirmed in CT scan Heart Team disqualified patient from cardiac surgery (mitral and aortic valve replacement and tricuspid valve annuloplasty). Afterward he was qualified to complex, percutaneous treatment – TAVI (trans-aortic valve implantation) in first stage, and transcatheter Mitraclip and Triclip implantation in second stage. The Portico transcatheter aortic valve (29mm) was implanted – max. grad. was 11 mmHg, residual small paravalvular leak was noted. Two weeks later transcatheter Mitraclip and Triclip implantation was performed and significant reduction of both MR (2+/3+) and TR (2+) was observed. Gradually after percutaneous treatment dyspnoea improved to class NYHA I/II and one month later patient was discharged to home. Discussion Percutaneous treatment of valvular heart diseases becomes a promising alternative for patients disqualified from cardiac surgery.

Abstract Introduction Congenitally Corrected Transposition of the Great Arteries (CCTGA) is a rare defect consisting in the abnormal twisting of the heart during fetal development. As a result, the two ventricles and their valves are reversed. CCTGA is frequently associated with other cardiac abnormalities. 25% of patients are developing heart failure, related to perfusion mismatch (the morphological left ventricle is supplied by a single coronary artery), and to the progressive deterioration of the structural right ventricle situated on the systemic side of the circulation. Case report A 45-year-old male was referred to our hospital for fatigue and dyspnea, occuring in the last five months. Physical examination revealed tachypnea, a slightly intense systolic murmur at the apex, and pulmonary congestion, in the absence of cyanosis, peripheral edema or jugular venous distension. Heart rate and blood pressure were normal. Usual laboratory work-up indicated increased levels of NT-proBNP, without any other abnormalities. ECG presented signs of pressure overload of the systemic ventricle (Figure Ia). Transthoracic echocardiography (TTE) highly suggested the diagnosis of CCTGA, due to atrioventricular valve displacement, with the morphological tricuspid valve closer to the apex in 4-chamber view (Figure Ib). TTE showed also dilated and dysfunctional left ventricle, mild left atrioventricular regurgitation, and normally functional right ventricle. Cardiac computed tomography emphasized a specific feature of CCTGA: the parallel emergence of aorta and pulmonary trunk, with the aortic arch crossing over the left pulmonary artery (Figure Ic). Cardiac magnetic resonance imaging confirmed dilatation and low ejection fraction of the systemic ventricle (20%), and displayed presence of trabeculations and the moderator band in the systemic ventricle (Figure Id). None of these evaluations found additional cardiac structural anomalies. Thus, patient was diagnosed with heart failure due to isolated CCTGA. Discussions and relevance of case report. This case emphasizes a very rare cause of heart failure in adults. CCTGA is reported in 0.5-1% of all congenital diseases, especially in males. Isolated CCTGA accounts for less than 10% of all cases, and represents the phenotype that is usually diagnosed in adulthood. In the absence of associated anomalies, the prognosis of these patients is particularly affected by the occurrence of heart failure in the 4th or 5th decade of life. Meanwhile, this case highlights the importance of a multimodal approach in CCTGA, and the specific contribution of each imaging method in the process of an accurate diagnosis. Abstract P1334 Figure I

Abstract Introduction Left ventricular non-compaction is a rare form of cardiomyopathy charactherized by the presence of a two layered ventricular wall- a thinner epicardial layer and an inner, non-compacted layer with prominent trabeculations associated with deep, intratrabecular recesses that communicate with left ventricle cavity. Clinical manifestations vary in severity, including symptoms of heart failure, thromboembolic events or arrhythmias. Left ventricular (LV) dysfunction leads to tethering of the mitral apparatus and is a cause for secondary significant mitral regurgitation. Case presentation We report the case of a 57 year-old female patient, diagnosed with severe mitral regurgitation one year before presentation, with severe heart failure (HF) symptoms, referred to our clinic for the surgical replacement of the mitral valve. Clinical examination revealed no signs of pulmonary or systemic congestion and systolic apical murmur. Blood tests were normal, except for the elevated BNP (552 pg/ml). Electrocardiogram showed sinus rhythm and left ventricular hypertrophy. Coronary angiogram did not identify any coronary artery lesions. Echocardiography revealed mildly dilated left ventricle, but wih proeminent trabeculations and two distinct myocardial layers with a non-compacted/compacted ratio of 2:1 in the anterior and lateral walls, diagnostic for left ventricular non-compaction cardiomyopathy. LV ejection fraction was 40% , with severe secondary mitral regurgitation due to significant antero-posterior dilation of the mitral ring, with intact mitral leaflets; mild pulmonary hypertension was present. Magnetic resonance imaging (MRI) identified a two layer antero-lateral myocardium and confirmed the echo diagnosis; there was no evidence of scarring as there was absent late gadolinium enhacement. In the absence of fibrosis on MRI or any arrhythmic events on repeated Holter ECG monitoring, the implantation of a cardiac defibrillator was deferred. Given the secondary cause for mitral regurgitation (LV dysfunction), specific HF medication with beta blocker and renin-angiotensin-aldosterone blockade was initiated and titrated to optimal doses. With medical treatment the evolution was favourable. Currently, 3 years after the initial diagnosis, 6 minutes walk test revealed good functional capacity (510 m), a BNP value of 104 pg/l, without any worsening of LV systolic function nor progression of pulmonary hypertension. Conclusion Left ventricular non-compaction cardiomyopathy is a rare cause of heart failure, but due to advances in imaging modalities and increasing awareness, its prevalence is growing. Its pathogenesis and prognosis largely remain unknown, but early and adequate initiation of neurohormonal medication may be just as essential in order to prevent complications and improve long term prognosis, as for other forms of cardiomiopathy, even in the presence of severe secondary mitral regurgitation.

Abstract A 42 year-old woman presented with moderate exertion dyspnea within the past months. She was hypertensive, with end stage-chronic kidney disease (CKD) on hemodialysis for 8 years, initially by arteriovenous fistula and then by central venous catheter. She associated thrombosis of both common femoral veins. Clinical examination revealed mild leg edema, hepatomegaly, III/VI systolic murmur, left brachiocephalic arteriovenous fistula with aneurismal dilation and subclavian central venous catheter. Resting ECG showed atrial flutter with variable block and biventricular hypertrophy. Lab studies highlighted mild anemia, glomerular filtration rate (MDRD) 13.5 ml/min/1.73m2, hyperhomocysteinemia. Transthoracic echocardiography revealed left ventricle (LV) with normal diameters and mild concentric hypertrophy, mild systolic LV dysfunction and diastolic dysfunction (Fig A), dilation of both atria, mild mitral regurgitation, dilated RV with moderate global dysfunction, moderate tricuspid regurgitation and secondary pulmonary hypertension (PH) with estimated systolic pulmonary artery pressure of 79 mmHg (Fig C), moderate pulmonary regurgitation, moderate dilatation of pulmonary artery. Vascular Doppler ultrasonography showed thrombosis of the arteriovenous fistula and of right jugular vein. To confirm PH, right heart catheterization was necessary. The intervention could not be realized on femoral approach due to thrombosis of both common femoral veins. We considered the jugular approach, but weighing the risks/benefits balance, with one functional jugular vein, we decided not going for it, as the jugular approach was the only vascular approach for dialysis. We performed left catheterization right after a dialysis session and an LV end-diastolic pressure of 13 mmHg was measured. The possible causes of PH considered in this case were the CKD by itself, a pulmonary thromboembolic component in a patient with hyperhomocisteinemia and thrombosis of both femoral veins and a left heart component given the borderline value of LV end-diastolic pressure. The patient received treatment with beta-blockers, blockers of the renin-angiotenins-aldosterone system, calcium channel blockers and oral anticoagulation. She was evaluated after two months describing improvement of symptoms. The resting ECG showed sinus rhythm and the echocardiography revealed improved parameters of LV diastolic function (Fig B), with reduction of systolic pulmonary artery pressure (Fig D) and improvement of right heart parameters. PH is a frequent complication in patients with CKD on hemodialysis. Possible mechanism of its development include RV overload with increased pulmonary flow or creating a fistula with an increased flow through arteriovenous shunt. Thromboembolic complications and hyperhomocysteinemia are other frequent findings in these patients. Despite all the above, the left heart involvement with LV diastolic dysfunction remains a common and amendable cause of PH in this setting. Abstract P1687 Figure.

Abstract A 88-year-old female was admitted for an anterior ST-segment elevation myocardial infarction (STEMI). Patient had a history of intermittent chest pain for 2 days with worsening on the day of admission. Electrocardiogram (ECG) at admission showed ST-segment elevation on leads from V2 to V6 and leads DI and aVL. Initial observation on the emergency department was described as unremarkable apart from the chest pain. Aspirin and Ticagrelor loading doses were administered and patient underwent emergent coronary angiography, which showed left anterior descendent artery occlusion after the emergence of second diagonal branch. Coronary angioplasty of this lesion was tried, with a total of 3 drug-eluted stents implantation but with no success as in the end there was no reflow of the artery. Patient was then admitted on cardiac intensive care unit, and on observation at that time there was a remarking holosystolic murmur. Transthoracic echocardiogram showed (apart from left ventricle systolic disfunction with akinesia of the apical segments as well as middle segments of the interventricular septum (IVS) and anterior wall) an apical IVS defect with a left to right shunt with a gradient of around 50mmHg evaluated by Doppler, and no signs of right ventricle overload. Case was promptly discussed with cardiothoracic surgery and it was decided that she was not a candidate to urgent surgical intervention. Patient had an initial evolution in Killip class II, and remained hemodynamically stable for the rest of the admission, having no signs of heart failure on discharge at 17 days later. Serial ETTs during admission and at discharge were similar to the evaluation performed at admission. In the meanwhile, during admission, case was discussed in multidisciplinary heart team with cardiothoracic surgery and interventional cardiology. Given the favourable evolution and comorbidities and frailty of the patient it was decided to adopt a conservative strategy with medical follow-up, only considering intervention if there was worsening of heart failure. Until now, with 4 months follow-up, patient remains in New York Heart Association (NYHA) functional class I. Discussion Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD. Abstract P862 Figure. Ventricular Septal Defect