Outpatient management of patients with structurally or functionally abnormal cardiac valves combines an ability to record an appropriate history, a directed physical examination, a knowledge of both the interpretation as well as the context of any associated testing, and an understanding of the care guidelines in the medical literature. This article attempts to integrate these various features to guide the clinician towards more appropriate and timely management of patients with cardiac valve disease.

Quadricuspid aortic valves are rare congenital anomalies, usually diagnosed in adult patients affected by severe aortic regurgitation. We have now encountered three such valves in children undergoing transthoracic echocardiography. All children were asymptomatic. The first child possessed a valve with two larger leaflets, and smaller leaflets of equal size. In the second child, 3 leaflets were of equal size, with 1 small accessory leaflet. The third child had a valve with four leaflets of approximately equal size. In one child, the aortic valve was functioning normally, and came to attention because of mitral valvar prolapse causing mild regurgitation. In the remaining two children, central mild aortic regurgitation was detected using colour flow analysis, and associated dilation of the aortic root was revealed by measurements of the cross-sectional images.

Disperser effectiveness is the contribution that a disperser makes to the future reproduction of a plant (Schupp 1993), and it has two components: quality and quantity of dispersal. Quantity of dispersal is a function of the number of visits that a disperser makes to a fruiting plant and the number of seeds that are dispersed during each visit. Quality of dispersal is a function of the treatment that a seed receives from its disperser and the site that the seed is finally deposited in. The quality of seed dispersal of the mistletoe Phragmanthera dschallensis (Engl.) M.G. Gilbert (Loranthaceae) by frugivorous birds was examined in this study.

Congenital anomalies of the tricuspid valve, and/or its supporting apparatus, leading to severe tricuspid regurgitation are rare. Although well tolerated in early childhood, long-standing and progressive volume loading of the right heart leads to symptoms of decreased exercise tolerance, and may predispose to arrhythmias in the long term. We report three cases of severe tricuspid regurgitation related to anomalies of the cords supporting the antero-superior leaflet of the tricuspid valve. Shortened cords leading to tethering of the leaflet were seen in two cases, and hypoplasia of the leaflet in the other. In all cases, the regurgitant jet was directed posteriorly towards the coronary sinus and atrial septum. Surgical repair was possible in one case, while it proved necessary to replace the valve in a second. The third child is asymptomatic and under regular review.

Trauma is often assumed to increase the risk of pulmonary aspiration of gastric contents. The 247 anaesthetists in the Trent region of England were surveyed by postal questionnaire to ascertain the current practice for identifying patients at risk of pulmonary aspiration of gastric contents following trauma. The response rate was 79%. The anaesthetists rated the reliability of several criteria when predicting ‘gastric safety’ and stated whether each criterion formed part of their clinical practice. Interval of eating to injury was the most used (88%) and highest rated criterion (4/5) followed by use of opioids. Presence or absence of bowel sounds was the least used (7%) and lowest rated criterion (0/5). Currently there is little evidence that the commonly used criteria accurately identify ‘at-risk’ patients. There is little evidence that trauma increases the risk of aspiration although a number of factors associated with trauma are known to delay gastric emptying.