Diagnostic Performance of Individual Symptoms to Predict SARS-CoV-2 RT-PCR Positivity and Symptom Persistence among Suspects Presenting in Primary Care during the First Wave of COVID-19

This study aimed to estimate the diagnostic performance of patient symptoms and to describe the clinical course of RT-PCR-positive compared with RT-PCR-negative patients in primary care. Symptomatic COVID-19 suspects were assessed clinically at the initial consultation in primary care between March and May 2020, followed by phone consultations over a span of at least 28 days. Sensitivity and specificity were estimated for each symptom using the initial RT-PCR result as a reference standard. The proportions of symptomatic patients according to the RT-PCR test results were compared over time, and time to recovery was estimated. Out of 883 patients, 13.9% had a positive RT-PCR test, and 17.4% were not tested. Most sensitive symptoms were cough, myalgia, and a history of fever, while most specific symptoms were fever for ≥4 days, hypo/anosmia, and hypo/ageusia. At the final follow up (median time 55 days, range 28-105 days), 44.7% of patients still reported symptoms in the RT-PCR-positive group, compared with 18.3% in the negative group (p < 0.001), mostly with hypo/anosmia (16.3%), dyspnea (12.2%), and fatigue (10.6%). The discriminative value of individual symptoms for diagnosing COVID-19 was limited. Almost half of the SARS-CoV-2-positive patients still reported symptoms at least 28 days after the initial consultation.

Trends in COVID-Related Activity in Sentinel Family Medicine Practices: An Observational Study

Objectives: During the COVID pandemic, data collected in family medicine were scarce. The COVID-FM project aimed to monitor trends of COVID-related activity in family medicine practices of the canton of Vaud, Switzerland, during the year 2021. Methods: Practitioners were invited to join an ad hoc sentinel surveillance system. Online data collection was based on daily activity reports and monthly questionnaires. Participants categorized daily counts of consultations and phone calls into predefined categories. Data were reported and discussed on a weekly basis with public health authorities. Results: On the target of 50 physicians, 37 general physicians from 32 practices finally constituted the COVID-FM sentinel network, contributing to 901 practice-weeks of surveillance in family medicine and 604 in paediatrics. In paediatrics, COVID-related activity corresponded mostly to COVID-19 diagnostic consultations (2911/25990 face-to-face consultations = 11.2%) while in family medicine, other COVID-related topics-such as questions on vaccination-predominated (4143/42221 = 9.8%). Conclusion: COVID-related consultations constituted an important part of primary care practices' activity in 2021. Monitoring COVID-related activity in primary care provided health authorities with valuable information to guide public health action.

Sentinel monitoring of COVID-related daily activity in primary care practices of the canton of Vaud

Introduction

During the COVID pandemic, COVID-related data collected in family medicine were scarce. We aimed to monitor cantonal trends of COVID-related activity in family medicine and paediatric practices during the year 2021.

Methods

Family physicians and paediatricians established in the canton of Vaud were invited to join an ad hoc sentinel surveillance system. Online data collection was based on daily activity reports and monthly questionnaires. In particular, participants categorized daily counts of consultations and phone calls into predefined COVID-related categories.

Results

Thirty-seven practices contributed regularly to the system between March 20th and December 31st 2021. Out of 81'407 medical consultations, 4'950 (6.1%) were related to new COVID suspicions as defined by the Federal Office of Public Health, and 5'252 (6.4%) otherwise related to COVID. Depending on the week and the practice, between 5.6% and 26.5% of face-to-face consultations were COVID-related. In paediatrics, COVID-related activity corresponded mostly to new COVID suspicions (11.2% of on-site consultations), whereas among family physicians other COVID topics predominated (9.8% of face-to-face consultations), mainly questions about vaccination. Consultations for persisting COVID-related symptoms were stable at a low level throughout the year, and constituted less than 1% of all consultations. Most practices swabbed patients for SARS-CoV-2 tests, and an increasing proportion performed rapid antigenic tests over the year. In paediatrics, COVID-suspicions were not systematically tested.

Conclusions

Throughout 2021, COVID-related consultations constituted an important part of family medicine and paediatric practices’ activity in the canton of Vaud. Monitoring COVID-related activity in primary care during a pandemic documents how physicians translate recommendations into practice and provides health authorities with valuable information to guide public health action.

Key messages

• Throughout 2021, COVID-related consultations constituted an important part of family medicine and paediatric practices’ activity in the canton of Vaud.

• Monitoring COVID-related activity in primary care during a pandemic documents how physicians translate recommendations into daily practice.

Detrimental effects of intense vasodilation in women with acute heart failure: novel insights from a prospective randomized controlled trial

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ according to sex. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes. However, sex-specific differences in heart failure pathophysiology and the effect of the strategy in women with AHF remained unclear.

Purpose

To characterize sex-specific differences in heart failure pathophysiology and to evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100 mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. The subgroup analysis according to sex was predefined.

Results

Among 781 patients who completed the trial, 288 (36.9%) were women. Women were significantly older, had a higher systolic blood pressure at presentation and a more common history of diastolic dysfunction (all ps&lt;0.05), whereas men had a significantly higher body surface area, a more common history of ischemic heart disease and a significant lower left ventricular ejection fraction (all ps&lt;0.05). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 35 female patients (23.6%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.3%; adjusted hazard ratio, 1.62 [95% CI, 1.05–2.50]; P=0.03).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Basel

Prognostic significance of left atrial reservoir strain in patients undergoing transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial reservoir strain (LARS) provides prognostic information in various patient groups and might help to detect elevated filling pressures. Patients with diastolic dysfunction experience worse outcomes after transcatheter aortic valve implantation (TAVI), but Doppler-derived measurements might be hampered by atrial fibrillation, mitral valve disease or impaired image quality. Aim of the current study is to elucidate the prognostic value of LASR in patients undergoing TAVI.

Methods

 All consecutive patients undergoing TAVI at a single tertiary care hospital between 01/2018 and 12/2018 were included if discharge echo and follow-up was available. LASR was derived from 2-D-speckle-tracking averaged apical 2- and 4-chamber view. Patients were grouped in 3 tertiles according to LASR. Primary outcome was a composite of all-cause death and readmission for worsening heart failure.

Results

Overall, 606 patients were available (Age 80 years (IQR 77-84)), including 53% woman. 

LASR was significantly impaired over tertiles (T1 21.4  (IQR 18.3-24.5), T2 13.0  (IQR 11.3-14.6), T3 7.1  (IQR 5.4-8.4), p &lt; 0.0001). The primary outcome occurred more often with impaired LASR (T1 7,4%, T2 13.4%, T3 25,7%). 

 On multivariable Cox-regression analysis LASR was a significant factor to predict outcome (HR 0.95, CI 0.91-0.99, p = 0.02).

Conclusion

Impaired LASR is associated with impaired outcomes in patients undergoing TAVI.

Discordance in prognostic ability between physician assessed NYHA classification and self-reported health status in patients with acute heart failure

Background

Especially in patients with acute heart failure (AHF) the NYHA classification remains of uncertain representation of patients' actual health state. Alternatively, patient's subjective well-being, in terms of health-related quality of life (HRQL), showed to have an excellent prognostic ability in out clinic patients with chronic heart failure.

Objectives

It is unknown whether HRQL instruments can assess a more reliable prognostication in patients hospitalized due to AHF than the NYHA classification.

Methods

Goal Directed Afterload Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a multicenter, randomized, open-label blinded-end-point trial that emphasized early intensive and sustained vasodilation in adult patients hospitalized due to AHF with NYHA functional class III/IV, however provided neutral findings. HRQL was assessed by the generic EQ-5D-3L which is a 3-leveled 5-item instrument and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ). Unadjusted and adjusted Cox regression models were performed after patients were grouped into low (EQ-5D −0.074&lt;0.25; KCCQ 0&lt;25), moderately low (0.25&lt;0.5; 25&lt;50), moderately high (0.5&lt;0.75; 50&lt;75) and high HRQL (0.75–1.0; 75–100).

Results

781 patients were enrolled in 10 centres in 5 countries over 2 continents among which 536 (69%) patientshad completed theEQ-5D and 419 (54%) the KCCQ shortly after admission. Within 180 days of follow-up69 (13%) and 54 (13%) patients died and 151 (28%) and 122 (29%) died or were rehospitalized due to AHF, respectively. Cumulative incidence as well as HRs in patients grouped according to NYHA (n=536) indicated a comparable or significantly lower risk in patients with NYHA IV: e.g. for the combined outcome HR 1.07 (95% CI 0.777–1.473) and aHR 0.463 (95% CI 0.245–0.875). Whereas HRs in patients grouped according to both, EQ-5D (n=536) and KCCQ (n=419), increased from the group with highest to the group with the lowest HRQL: e.g. aHR for moderately high 1.11 (95% CI 0.718–1.715), for moderately low 1.721 (95% CI 1.102–2.688) and for low EQ-5D index 1.891 (95% CI 1.136–3.149) referenced to high HRQL (EQ-5D index 0.75–1.0).

Conclusions

These findings corroborate and extend previous work suggesting that NYHA classification poorly discriminates AHF patients' prognosis and challenge its' extensive application. HRQL might be a possible alternative to easily assess these patients' heath state.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation A. 180-day mortality; B. composite outcome

Serotypes of Streptococcus pneumoniae in Children Aged <5 Years Hospitalized With or Without Pneumonia in Developing and Emerging Countries: A Descriptive, Multicenter Study

BACKGROUND

Improving knowledge regarding Streptococcus pneumoniae distribution in pneumonia cases is important to better target preventive and curative measures. The objective was to describe S. pneumoniae serotypes in children with or without pneumonia.

METHODS

It was a case-control study carried out in 8 developing and emerging countries between 2010 and 2014. Cases were children aged <5 years admitted to the hospital for pneumonia. Controls were children admitted for surgery or routine outpatient care.

RESULTS

In nasopharyngeal samples, S. pneumoniae were detected in 68.2% of the cases and 47.5% of the controls (P < .001). Nasopharyngeal carriage was associated with a higher risk of being a case in 6/8 study sites (adjusted odds ratio ranged from 0.71 [95% confidence interval [CI], .39-1.29; P = .26] in India [Pune/Vadu] to 11.86 [95% CI, 5.77-24.41; P < .001] in Mongolia). The 13-valent pneumococcal conjugate vaccine (PCV13) serotypes were more frequently detected in cases with nasopharyngeal carriage (67.1%) than in controls with nasopharyngeal carriage (54.6%), P < .001. Streptococcus pneumoniae was detected in blood by polymerase chain reaction in 8.3% of the cases. Of 34 cases with an S. pneumoniae serotype detected in blood, 27 (79%) had the same serotype in the nasopharyngeal sample.

CONCLUSIONS

The results confirm the assumption that the isolate carrying or causing disease in an individual is of the same serotype. Most serotypes independently associated with nasopharyngeal carriage or pneumonia are covered by PCV13, suggesting that increased PCV coverage would reduce the burden of S. pneumoniae-related pneumonia.

Effect of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization in women with acute heart failure

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ between women and men. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes.

Purpose

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

Results

Among 788 patients randomized, 781 completed the trial and were eligible for the primary end point analysis. Of these 288 (36.9%) were women. The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 34 female patients (23.0%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.9%; adjusted hazard ratio, 1.67 [95% CI: 1.08–2.59]; P=0.02). Clinically significant adverse events with early intensive and sustained vasodilation vs usual care included hypotension (8% vs 2%).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Cox Proportional Hazard Curve

Funding Acknowledgement

Type of funding source: None

Calculation of equilibrium constants from multiwavelength spectroscopic data-I Mathematical considerations

Multiwavelength spectrophotometric and spectroscopic data in general contain considerably more information about complexation equilibria than potentiometric data do. With the construction of a fully automatic titration set-up built into a high-precision spectrophotometer, the problems related to the wider use of this method have shifted from the quality of the primary data to the complexity of their numerical treatment. Matrix algebra is used to show how these problems can be overcome. An algorithm is described for calculation of stability constants and absorption spectra, together with the associated standard errors, at a reasonable expense of computer time. Problems in finding the minimum in a multidimensional parameter space are reduced by elimination of the molar absorptivities from the algorithm for the iterative refinement. Numerical safety and speed of calculation are improved by use of analytical instead of numerical derivatives. The number of data to be fitted is decreased by principal-component analysis.

Model-based analysis for kinetic complexation study of Pizda and Cu(II)

In the present work, the multivariate kinetic complexation of a new synthesized ligand, 1-(2''-hydroxyl cyclohexyl)-3'-[aminopropyl]-4-[3'-aminopropyl]piperazine (Pizda) and Cu(2+) in 50% ethanol-water solution is investigated using the UV-vis stopped-flow technique and state-of-the-art multi-wavelength numerical analysis. Model-based least squares fitting analysis or hard modeling is a specific part of chemometrics which is based on mathematical relationships for describing the measurements. Some recent developments include the incorporation of the effects of non-ideal experimental conditions into the fitting algorithm so it can substantially simplify experimental procedures. In this study no buffers are required because pH changes are taken into computations. Some 21 multi-wavelength kinetic measurements, taken at various initial concentrations of [H(+)] were analyzed globally, i.e. simultaneously applying an all inclusive reaction mechanism and a common set of species spectra. Using numerical analysis, the pH of the experimental solutions was allowed to vary as a consequence of the proceeding reactions. This enabled the complete kinetic analysis of the formation and dissociation of Cu(Pizda)(n+). Here protonation equilibria have been directly incorporated into the rate law, so thus variable pH values have been allowed during each measurement. Using the independently estimated stability constants (from spectrophotometric and potentiometric measurements) for the Cu(Pizda)(n+) complexes, a total of six rate constants and one protonation constant could be elucidated. The results of the analysis include the concentration distribution and spectra of all chemical species involved in the reaction. A low standard deviation and residual profiles obtained validate the results.

N-terminal pro-brain natriuretic peptide used for the prediction of coronary artery stenosis

BACKGROUND

The level of the inactive N-terminal fragment of pro-brain (B-type) natriuretic peptide (NT-proBNP) is a prognostic marker in patients with acute and chronic coronary artery disease (CAD). It might also be valuable for non-invasive diagnosis of coronary artery disease.

MATERIALS AND METHODS

The NT-proBNP was measured in 781 consecutive patients with normal left ventricular function referred for coronary angiography owing to symptoms or signs of CAD. The diagnostic value of NT-proBNP was assessed for predicting CAD at angiography.

RESULTS

Elevated NT-proBNP levels were associated with the extent of CAD and with the female sex (P < 0.001). The ability of NT-proBNP to predict significant coronary disease at angiography was assessed separately for men using a cut-off point of 85 pg mL(-1), positive likelihood ratio 2.2 (95% CI, 1.7-3.0), negative likelihood ratio 0.53 (95% CI 0.45-0.63) and area under the receiver-operating-characteristic (ROC) curve 0.72: for women, it was assessed using a cut-off point of 165 pg mL(-1), positive likelihood ratio 2.4 (95% CI, 1.7-3.4), negative likelihood ratio 0.55 (95% CI, 0.44-0.70) and area under ROC curve 0.71. In multiple logistic-regression analysis, NT-proBNP added significant independent predictive power to other clinical variables in models predicting CAD (odds ratio 2.76, 95% CI, 1.76-4.32, P < 0.001).

CONCLUSIONS

The NT-proBNP is a marker of non-obstructive CAD and of significant coronary stenosis. In conjunction with other clinical information, measurement of NT-proBNP with the use of sex-specific reference ranges may improve the non-invasive prediction of CAD.

Bland-White-Garland syndrome and atrial septal defect - rare association and diagnostic challenge

We report on a 40-year-old woman referred for evaluation of a cardiac murmur and dyspnea on exertion. The electrocardiogram (ECG) showed incomplete right bundle branch block, and echocardiography revealed a large atrial septal defect (ASD, ostium secundum type) with dilated right-sided heart chambers. At cardiac catheterization, a large left-to-right shunt (78% of the pulmonary blood flow) was found, and surprisingly, the additional diagnosis of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) was established. After ASD closure and left coronary artery ligation with implantation of a vein graft to the left anterior descending artery, she had an uneventful 18-years follow-up. We discuss the interaction of the two associated conditions, and based on the herein reported unusual combination, we highlight typical features of non-invasive examinations including auscultation, ECG, and echocardiography in adult patients with ALCAPA.

Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment

We report on a 22- year-old woman with postpartum dissection of the left anterior descending artery and the intermediate branch. The patient was treated with acetylsalicylic acid (ASA), clopidogrel, and betablocker only. Coronary angiography performed 20 months later revealed complete resolution of the dissection sites. The patient's cardiovascular risk factors included mild smoking and high total cholesterol and low-density-lipoprotein-cholesterol levels, which showed a marked fall after pregnancy without pharmacological cholesterol-modifying therapy raising the question whether pregnancy-related hypercholesterolemia contributed to the pathogenesis of pregnancy-associated spontaneous coronary artery dissection (P-SCAD). In a systematic review of the literature, 16 women [median age 34 (31-36.5) years] with P-SCAD and angiographic follow-up were identified. The majority (69%) of P-SCAD cases occurred postpartum [median time after delivery: 13 (7-21) days]. In 10/16 (63%) patients medical treatment including betablocker and antiplatelet therapy was given leading to complete resolution of the dissection in 5 of them (31% of all patients) at follow-up, whereas in the other 5 patients the dissections were persisting or even progressive. Of the medically treated patients, 80% were free of symptoms suggestive for ischemia at follow-up. In 5/16 patients percutaneous coronary intervention (PCI) was performed as first-line therapy. Three patients underwent coronary artery bypass grafting, which was performed primarily in one patient, and secondarily in two patients with persisting dissections and ongoing ischemic symptoms after previous medical treatment or PCI without stenting, respectively. In conclusion, medical treatment including ASA, clopidogrel and betablocker therapy results in an excellent clinical and angiographic result in approximately one third of patients with P-SCAD.

Synthesis and reactivity of the macrobicyclic complexes (1,5,8,12-tetraaza-17-oxabicyclo[10.5.2]nonadecane)cobalt(III) perchlorate ([Co(L1)(ClO4)](ClO4)2), [(chloro(1,4,8,11-tetraaza-17-oxabicyclo[9.5.3]nonadecane)cobalt(III) perchlorate ([Co(L2)(Cl)](ClO4)2), (4,8-dimethyl-1,4,8,11-tetraaza-17-oxabicyclo[9.5.3]nonadecane)cobalt(III) perchlorate ([Co(L3)(ClO4)](ClO4)2), and (5,8-dimethyl-1,5,8,12-tetraaza-17-oxabicyclo[10.5.2]nonadecane)cobalt(III) perchlorate ([Co(L4)(ClO4)](ClO4)2) — Crystal structure of the L2 complex

The potentially penta-coordinating ligands L2 and L3 have been synthesized by reaction of the 10-membered macrocycle 1,5-diaza-8-oxacyclodecane with either 1,9-dichloro-3,7-diazanonane-2,8-dione, and subsequent reduction of the diamide (3), or with 1,9-dichloro-3,7-(dimethyl)diazanonane-2,8-dione and reduction (L3). A similar procedure is outlined for the dimethylated macrobicycle (L4), based on the corresponding nine-membered 1,4-diaza-7-oxacyclononane. The Co(III) complexes of these ligands and of 1,5,8,12-tetraaza-17-oxabicyclo[10.5.2]nonadecane (L1) have been prepared. Spectrophotometric determinations on the L1 complex ion confirm the presence of two hydrogen ion related equilibria, one of which (pK = 2.2 ± 0.2) is associated with the proposed replacement of the apical ether oxygen by a water molecule that is bound to the metal centre and hydrogen bonded to the ether. The species derived from L1 and L2 exhibit remarkable kinetic stability. Studies on the anation of the [Co(L1)(H2O)](ClO4)3 with chloride ions in acidic media are consistent with the reaction of both the proton-related complex and the [Co(L1)(H2O)]3+ ion. Whilst complex ions containing two secondary NH groups maintain the metal–ion coordination in strongly acidic media, corresponding species with ligands containing all four tertiary amine sites are subject to attack by protons leading to a relatively facile demetallation of the complexes. The latter finding is supported by kinetic studies and mass spectrometric fragmentation patterns of the ions. Key words: cobalt(III), macrobicycle, hydrolysis, anation, spectroscopic analysis.

[Impact of endoscopic ultrasonography in the diagnosis of aberrant right subclavian artery: a case report]

Aberrant right subclavian artery (ARSA) is the most common anomaly of the aortic arch. We present the successful use of endoscopic ultrasonography (EUS) in the diagnosis of ARSA. A 65-year-old woman was admitted because of dyspnoea and inspiratory stridor. Bronchoscopy revealed a subglottic tracheal stenosis. To exclude an underlying malignancy, endoscopy was performed showing an oesophageal impression, which subsequently was identified as ARSA by EUS. Computed tomography excluded neoplasm and confirmed the diagnosis of ARSA. After laser resection of subglottic tissue the stridor resolved and could therefore not be attributed to the co-existence of ARSA. In most cases the ARSA crosses between the oesophagus and the spine from the descending aortic arch to the right and may seldom cause dysphagia due to oesophageal compression. Diagnosis is usually based upon computed tomography or magnetic resonance imaging, whereas angiography is only rarely needed. Endoscopic ultrasonography offers a convenient alternative diagnostic tool and can be performed even as a bedside examination. The diagnosis can be easily assessed in all patients referred for EUS of the upper gastrointestinal tract for any reason. Especially in patients undergoing invasive procedures in the upper thorax or neck, knowledge of an abnormal course of the great vessels is important. Arteria lusoria is often found by chance. EUS is a simple and excellent tool for assessing the diagnosis and usually does not require confirmation through other investigation methods.

Aortic homograft endocarditis caused by Rhodotorula mucilaginosa

Serious infections caused by Rhodotorula spp. are rare and usually occur in immunocompromised people, especially in patients with tumors and long-time use of indwelling central venous catheters. We report a case of Rhodotorula mucilaginosa homograft endocarditis in an otherwise healthy man, which was successfully treated by surgery in combination with amphotericin B and subsequently intraconazole.

[A case of coronary vasospasm treated with stent placement]

We report about a 49 year old woman with repeated chest pain at rest. During hyperventilation significant ST-segment elevation in leads V1-V5 appeared. Bicycle stress test did not provoke any ECG changes. Coronary angiography showed a significant stenosis of the left anterior descending coronary artery. Successful balloon angioplasty followed by stent implantation was performed. After an uneventful course of twelve months, hyperventilation could provoke neither chest pain nor ECG changes again without any antispastic medical treatment. Impact of fixed atherosclerotic lesions for the occurrence of coronary vasospasm, usefulness of hyperventilation as a non-invasive provocation test and therapy are discussed.

[Spontaneous coronary artery dissection as a rare cause of an acute coronary syndrome]

Spontaneous coronary artery dissection is a rare cause of an acute coronary syndrome. This report describes a previously healthy woman without cardiovascular risk factors who presented with an acute anterior non-ST elevation myocardial infarction. Coronary angiography revealed an isolated longitudinal dissection in the middle part of the left anterior descending coronary artery (LAD) with normal flow of the contrast media. The patient was treated conservatively with heparin, aspirin, clopidogrel, and beta-receptor blocker. Stress exercise test was normal at discharge. After an event-free follow-up of three and a half months coronary angiography showed a completely normal LAD. Literature about epidemiology, pathogenesis, diagnosis and treatment of spontaneous coronary artery dissection is reviewed.

Synthesis and Complexation of a Chiral Sexidentate Pendant-Arm Macropolycyclic Polyamino Acid

The reaction of the acyclic complex ion (methyl (SS,SS)-3-[(2�-aminocyclohexyl)amino]-2-[(2�-aminocyclohexyl)-aminomethyl]propionate)copper(II) with formaldehyde and nitroethane in basic solution yields the pendant-arm macrocyclic complex (SS,SS)-(methyl-15-methyl-15-nitro-2,6,13,17-tetraazatricyclo[16.4.0.07,12]docosane-4-carboxylate)copper(ii) ion. Reduction with zinc in hydrochloric acid yields the hydrochloride salt of the pendant-arm macrocycle (SS,SS)-15-amino-15-methyl-2,6,13,17-tetraazatricyclo[16.4.0.07,12]docosane-4-carboxylic acid (1), separated into and isolated as the major trans (1a) and minor cis (1b) isomers. Co-ordination of (1) to several metal ions [CoIII, CrIII, NiII, ZnII, CuII] and comparison with a previously reported analogue without the cyclohexane rings, trans-13-amino-13-methyl-1,4,8,11-tetraazacyclotetradecane-6-carboxylic acid (2a) salt, is described. The [Ni{(1a) – H+}](ClO4) crystallizes in the monoclinic space group P21, a 9.710(2), b 14.442(1), c 10.317(2) Å, β 96.02(2)°. The nickel displays a distorted octahedral geometry, with all four secondary amines coordinated (Ni–N range 2.044(7)–2.063(6) Å), in addition to pendant primary amine (Ni–N, 2.109(6) Å) and carboxylate (Ni–O, 2.100(6) Å) groups. Protonation constants for the trans (1a) and cis (1b) isomers and stability constants of these isomers with the labile metal ions ZnII, CdII, HgII, PbII, MnII, and CoII were determined by potentiometric titrations. The log K values for 1 : 1 complexes show small variations between geometric isomers.

Technical Considerations in the Repair of Combined Aortic Arch and Diaphragm Rupture after Blunt Trauma

Rupture of the aortic arch and laceration of the diaphragm after blunt trauma are two serious lesions that are difficult to manage. (1,2) We repaired both lesions in a patient with an anterior approach (i.e., a median sternotomy and a superior median laparotomy). The repair, carried out during extracorporeal circulation, turned out to be relatively easy to perform. The potential dangers associated with the use of cardiopulmonary bypass after blunt trauma must be acknowledged. In selected cases, however, when no strong contraindications to the administration of anticoagulation exist, the anterior approach and the use of cardiopulmonary bypass offer an excellent exposure for the repair of both lesions.

Resolving factor analysis

Bilinear data matrices may be resolved into abstract factors by factor analysis. The underlying chemical processes that generated the data may be deduced from the abstract factors by hard (model fitting) or soft (model-free) analyses. We propose a novel approach that combines the advantages of both hard and soft methods, in that only a few parameters have to be fitted, but the assumptions made about the system are very general and common to a range of possible models: The true chemical factors span the same space as the abstract factors and may be mapped onto the abstract factors by a transformation matrix T, since they are a linear combination of the abstract factors. The difference between the true factors and any other linear combination of the abstract factors is that the true factors conform to known chemical constraints (for instance, nonnegativity of absorbance spectra or monomodality of chromatographic peaks). Thus, by excluding linear combinations of the abstract factors that are not physically possible (assuming a unique solution), we can find the true chemical factors. This is achieved by passing the elements of a transformation matrix to a nonlinear optimization routine, to find the best estimate of T that fits the criteria. The optimization routine usually converges to the correct minimum with random starting parameters, but more difficult problems require starting parameters based on some other method, for instance EFA. We call the new method resolving factor analysis (RFA). The use of RFA is demonstrated with computer-generated kinetic and chromatographic data and with real chromatographic (HPLC) data. RFA produces correct solutions with data sets that are refractory to other methods, for instance, data with an embedded nonconstant baseline.

Benign partial epilepsy of childhood: a longitudinal neuropsychological and EEG study of cognitive function

The study combined prospective neuropsychological and EEG results of 22 children presenting with typical benign partial epilepsy with rolandic spikes (n=19) and occipital spikes (n=3). The aims were to assess the types of cognitive problems which may be encountered in this population, to evaluate the course of cognitive and learning capacities during the active phase of epilepsy, and to see if there was a correlation with paroxysmal activity on the EEG. Average age at entry in the study was 8.4 years and each child was seen two to four times over a period of 1 to 3 years. EEGs showed persistent spike foci in most cases that worsened in three cases, but there were no continuous spike-waves during sleep. No child had persistent stagnation, marked fluctuations, or a regression in cognitive abilities. Of 22 children, 21 had average IQ (>80). Eight children had school difficulties requiring special adjustment. No single cognitive profile was identified. Four children had delayed language development and eight children had transient weak scores in one isolated domain (verbal, visuospatial, memory) which improved or normalized during the course of the study with concomitant EEG improvement or normalization. In two of the three children with aggravation of the paroxysmal EEG activity, clinical changes were documented. A proportion of children with typical benign partial epilepsy with rolandic spikes showed mild, varied, and transient cognitive difficulties during the course of their epilepsy, and in most cases this probably had a direct relation with the paroxysmal EEG activity.

Are there clinical and laboratory predictors of 5-year mortality in HIV-infected children and adolescents with hemophilia?

To determine factors associated with survival in a cohort of HIV-infected children and adolescents with hemophilia, an analysis of the 5-year mortality data for 207 HIV-infected young men was performed to examine the effect of selected clinical covariates on survival. The subjects were enrolled into the Hemophilia Growth and Development Study cohort from 1989 to 1990. Estimated mean time since infection at baseline was 6.7 years and mean estimated age at infection was 6.5 years. The baseline characteristics examined for their association with the hazard of death over the 5-year follow-up period were the following: absolute CD4+ cell count, hemoglobin status, skin test anergy, results of brain magnetic resonance imaging, non-hemophilia-related muscle atrophy (NHRMA), height for age, and impaired neuropsychological functioning as measured by the Vineland Adaptive Behavior and the Pediatric Behavior Scales. In all, 66 deaths occurred over the 5-year follow-up, 62 of whom met the 1987 (n = 56) or 1993 (n = 6) U.S. Centers for Disease Control and Prevention (CDC) definition of AIDS. Although each of the characteristics listed previously significantly increased the hazard of death by Cox proportional hazard regression models, only NHRMA remained a significant predictor of AIDS-related death when added to models that included each of the other cited baseline covariates.

The Influence of Alkyl Substituents on Carbon Acid Formaldehyde Condensation Reactions of Bis(alkane-1,2-diamine)copper(II) Ions

The reaction of the bis (1,2-diamine)copper(II) complexes of ethane-1,2-diamine (en), propane-1,2-diamine ( pn ) and 2-methylpropane-1,2-diamine ( dmen ) with formaldehyde and nitroethane in methanol under basic conditions yields macrocyclic and acyclic condensation products with two or one new -NH-CH2-C(Me)(NO2)-CH2-NH- links introduced respectively between pairs of cis-disposed primary amines, and where the ratio of products is, surprisingly, significantly altered by C-methyl substitution on the parent ethane-1,2-diamine chelate . Under identical reaction conditions, the ratio of acyclic to macrocyclic product varied from 2:3 (en) to 10:1 ( pn ) to 50:1 ( dmen ) as first one methyl and then gem- dimethyl groups are attached to each parent chelate ring. That the reaction is influenced by substituent steric effects is supported by the structural characterization of the zinc-acid reduced and recomplexed acyclic species, which indicates that first ring formation occurs at amine pairs distant from the C-methyl substituents. The μ-chloro-bis (6-methyl-4,8-diazaundecane-2,6,10-triamine) dicopper (II) perchlorate crystallized in the space group C2/ c, a 23.003(6), b 12.641 (3), c 19.120(6) Ǻ, β 127.88(2)°, whereas the (2,6,10-trimethyl-4,8-diazaundecane-2,6,10-triamine)copper(II) perchlorate crystallized in the space group Cc2a, a 43.769(3), b 14.509(3), c 17.750(8) Ǻ. The copper ion is found in a distorted octahedral environment in the former with two complex units weakly bridged by a chloride anion, and in a square-based pyramidal environment in the latter.

Temperate bacteriophages are common among Actinobacillus actinomycetemcomitans isolates from periodontal pockets

Actinobacillus actinomycetemcomitans is a suspected etiologic agent in destructive periodontal diseases. The detection of bacteriophages in A. actinomycetemcomitans in the subgingival plaque of patients with rapidly destructive forms of periodontitis led to the hypothesis that bacteriophage infection might increase the virulence of this bacterium (19). A. actinomycetemcomitans was isolated from 68 subjects from the Netherlands and Switzerland with localized juvenile periodontitis, rapidly progressing periodontitis, or adult periodontitis, and was tested for the presence of temperate bacteriophage with the overlay plate technique. More than half of the A. actinomycetemcomitans strains were found to release bacteriophage which formed individual plaques on indicator strains. Electron microscopy of preparations from 7 strains revealed virions with an icosahedral head and a contractile tail typical for double-stranded DNA bacteriophages. The presence of A. actinomycetemcomitans carrying temperate bacteriophage was not correlated with the composition of the subgingival microflora nor with the clinical form of periodontal disease. Destructive periodontal disease of subjects with phage-carrying A. actinomycetemcomitans was not more severe than of subjects with phage-free A. actinomycetemcomitans as determined by several clinical parameters. In contrast, the pocket depth and the attachment loss were significantly lower for adult periodontitis subjects with phage-carrying A. actinomycetemcomitans. It seems unlikely that the frequently occurring temperate bacteriophages increase significantly the virulence of A. actinomycetemcomitans.

Metal-Directed Synthesis of Dithia Diaza Macrocycles Carrying Pendant Alcohol and Also Nitro or Carboxylate Groups

Copper(II)-directed condensation of 1,9-diamino-3,7-dithianonan-5-ol with nitroethane or di-ethyl malonate yields (6-methyl-6-nitro-1,11-dithia-4,8-diazacyclotetradecan-13-ol)copper(II) and (diethyl 13-hydroxy-1,11-dithia-4,8-diazacyclotetradecane-6,6-dicarboxylate)copper(II) respectively in good yields, with the latter readily converted by decarboxylation into the complex of ethyl 13-hydroxy-1,11-dithia-4,8-diazacyclotetradecane-6-carboxylate. Analogues without the alcohol group based on 3,7-dithianonane-1,9-diamine are also described. The pendant alcohol group fused directly to a macrocyclic ring carbon can act as an axial donor group, as illustrated in the X-ray crystal structure analysis of (diethyl 13-hydroxy-1,11-dithia-4,8-diazacyclotetradecane-6,6-dicarboxylate)copper(II) perchlorate . This complex crystallizes in the P21/c space group, a 12.650(3), b 8.620(1), c 24.382(4) Ǻ, β 96.10(2)°. The copper ion lies in a distorted square-based pyramidal environment of two sulfur donors (average Cu-S 2.338 A), two nitrogen donors (average Cu-N 2.035 Ǻ) and the pendant alcohol donor [Cu-O 2.319(6) Ǻ], with the copper ion displaced slightly (0.043 Ǻ) out of the macrocycle donor plane towards the pendant alcohol donor.

Metal-Directed Synthesis of Macrocyclic Tetraamines With Pendant Nitro or Amine Groups, Based on trans-Cyclohexane-1,2-diamine

Reaction of R,R:S,S-, R,R:R,R(or S,S:S,S)- bis (trans-cyclohexane-1,2-diamine)copper(II) with formaldehyde and nitroethane in aqueous base yields the macrocyclic molecular cation (4,15-dimethyl-4,15-dimethyl-4,15-dinitro-2,6,13,17-tetraazatricyclo[16.4.0.07,12] docosane )copper(II) with two -NH-CH2-C(Me)(NO2)-CH2-NH-links completing the macrocycle, as well as the molecular cation [N,N′- bis (2-aminocyclohexyl)-2-methyl-2-nitropropane-1,3-diamine]copper(II) with a single such link inserted. The rigid polycylic macrocycle , based on a 14-membered tetraazacycloalkane ( cyclam ) frame, may exist as a number of isomers. Spectroscopic and chiroptical properties of the isolated complexes are reported. Reduction of the nitro groups with zinc in aqueous acid produces the corresponding molecules with primary amine (or ammonium) pendants in good yield, as metal-free hydrochloride salts.

Diammonium Salts Derived From 1,4-Diazabicyclo[2.2.2]octane

The syntheses of a range of quaternary diammonium and some monoammonium salts derived from 1,4-diazabicyclo[2.2.2]octane with N-alkyl arms or N-alkyl arms terminated by a functional group are reported. In aqueous solution they are susceptible to only very slow Hofmann elimination, and the kinetics were investigated for the 1-(2′-ammonioethyl)-4-dodecyl-1,4-diazoniabicyclo[2.2.2]octane ion, which undergoes a base-induced elimination ( kOH 6.9×10-4 dm3 mol-1 s-1 at 55°C) consistent with an ElcB mechanism. In aqueous solution, the diammonium cations are not oxidized but undergo irreversible electrochemical reduction below -1.2 V v . Ag/ AgCl , with the reduction potential apparently influenced by the electron-withdrawing or -donating nature of substituent arms.

Coordination of 5-Methyl-3,7-diazanonane-1,5,9-triamine (L) to Rhodium(III). Crystal Structure of fac-[Rh(H2L)Cl3] Cl(ClO4).3H2O

The branched, potentially quinquedentate , 5-methyl-3,7-diazanonane-1,5,9-triamine (1) reacts in hot water with rhodium(III) chloride to yield fac -[ Rh (H2(1))Cl3]2+. Only upon extended reflux for several weeks is coordination as a quinquedentate achieved. The fac complex was crystallized readily as a mixed chloride perchlorate trihydrate salt, in the triclinic space group Pī , a 8.666(2), b 10.319(2), c 12.558(3) Ǻ, α 94.34(2), β 98.86(2), γ 97.75(2)°, Z = 2; a single-crystal X-ray structure determination was refined to Rw 0.037 for 3703 'observed' reflections. The central primary amine and two adjacent secondary amines occupy an octahedral face, with the chloro ligands then necessarily fac also. The Rh -N distances vary, with the shortest distance to the primary amine [2.023(2)Ǻ] rather than to the secondary amines [2.066(2), 2.077(2) Ǻ], as do the Rh-Cl distances [range 2.345(1)-2.369(1)Ǻ]. The two primary amines on the chain terminals remain uncoordinated, the central facially capping unit preferring coordination first, possibly indicating a general intermediate for coordination of polydentate l igands containing this type of unit.

Crystal Structure of a Luminescent Europium(III) Complex: Probing the Active Species in Dissociation-Enhanced Lanthanide Fluoroimmunoassay

The highly luminescent complex [ Eu ( fnac )2( topo )2(NO3)], which contains the two component ligands [ fnac, the anion of 4,4,4-trifluoro-1-(2-naphthyl)butane-1,3-dione, and topo, trioctylphosphine oxide] of the luminescent species in the dissociation-enhanced lanthanide fluoroimmunoassay method, has been prepared and defined by an X-ray crystal structure analysis. The complex crystallizes in the Ccmm space group, a 17.064(18), b 30.254(21) and c 16.391(4) Ǻ, Z = 4, and a single-crystal X-ray structure determination refined to R 0.056 for 1772 independent 'observed' reflections. The complex exhibits a dodecahedral EuO8 structure with bidentate nitrate ion [ Eu -O 2.512(10)Ǻ], two bidentate substituted acetylacetonate ( fnac )[ Eu -O 2.379(9), 2.400(9)Ǻ], and two monodentate long-chain phospine oxide ( topo ) ligands [ Eu -O 2.295(9)Ǻ].

Artefacts and morphological changes during chemical fixation

The normally 'condensed' (darkly stained) chromosomes of dinoflagellates decondense by swelling. This occurs in an increasing number of cells when the concentration of added OsO4 is decreased. With different fixatives other types of disintegration can be observed, which vary with the concentration. With cryofixation and freeze-substitution the chromosomes are most 'condensed'. Escherichia coli infected with bacteriophage T4, with or without active lysozyme production, were studied by optical densitometry for partial lysis and by light and electron microscopy for observing swelling. When active lysozyme is present some of the acrolein (2.5%)-glutaraldehyde (2%)-fixed cells swell at 0 degrees C, but do not in the absence of lysozyme nor when fixed at room temperature. If OsO4 is added at concentrations < or = 0.5%, partial lysis occurs when lysozyme is present. The optical density decreases, the cells lose some matter and swell slightly. The corresponding electron micrographs show gap formation by curdling and/or a decreased concentration of the cytoplasm which reveals certain phage-related particles.

In vitro evaluation of marginal fit and morphology of fired ceramic inlays

The marginal adaptation of fired ceramic inlays prepared by three dental technicians in two ceramic materials was evaluated in vitro. The thickness of the sealing gap varied between 46.4 and 57.6 microns, and the percentage of marginal ceramic defects ranged between 8.6% and 25.0% of the total inlay circumference. The incidence of marginal defects increased in areas of complex occlusal morphology. Differences observed in inlay adaptation were related to the technician rather than to the material used. The accuracy of ceramic inlays was comparable to that of metallic and porcelain-fused-to-metal crowns with butt-joint margins and fell within the range of clinically acceptable adaptation.

MR-imaging of chronic spinal cord injury. Association with neurologic function

Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.

Macrocycle Formation From Copper(II)Directed Condensation of Linear Tetraamines With Formaldehyde Alone and With Added 2-Aminoethanol

Reaction of several tetraaminecopper(II) complexes with paraformaldehyde in acetonitrile or dioxan yields oxatetraazacycloalkanecopper(II) complexes, with a new -NH-CH2-O-CH2-NH-link completing the cyclization. The complexes are stable in aqueous acid for appreciable lengths of time, but eventually decompose, with the precursor tetraaminecopper(II) the major product. In alcohol with aqueous formaldehyde, the products are not detected. However, aqueous formaldehyde reacts with a methanolic solution of the copper(II) complex of 4,7- diazadecane-1,10-diamine in the presence of added 2-aminoethanol to produce the polycyclic polyamino ether complex (3-oxa-1,6,8,12,15-pentaazatricyclo[13.3.1.1.8,12]icosane)copper(II) perchlorate. This complex crystallized in the monoclinic space group C2/c, a 32.777(8), b 9.395(2), c 14.914(6)Ǻ, β 111.97(2)°. The structure identifies three -NH-CH2-NH- links, two as parts of new diazacyclohexane rings, and a single -O-CH2-NH- link, all arising from condensation of the polyamine and/or the amino alcohol with formaldehyde. The copper ion lies in a plane of three nitrogens [Cu-N 1.976(4), 2.012(4) and 2.020(3)Ǻ] and the ether oxygen [Cu-O 2.008(3)Ǻ].

In vitro resistance to fracture of porcelain inlays bonded to tooth

To assess the resistance to fracture of ceramic inlays, extracted sound human molars were restored with different ceramic materials and glass-ionomer or composite resin luting cement. Compression forces were applied to the specimens until they fractured, and maximal force developed, extent and location of fractures, and the micromorphology of the fractured surfaces were studied. Inlays made of Vitadur N with aluminum oxide profile and bonded with composite resin demonstrated the highest resistance among the restorative combinations, but their resistance was still lower than that of intact (control) teeth. The extent of fracture increased proportionally to the fracture resistance of the specimens. Scanning electron microscopic observation confirmed the effectiveness of the adhesion between composite resin and etched ceramic and the absence of sufficient micromechanical anchoring between glass-ionomer cement and etched ceramic.

Basic nuclear proteins of the histone-less eukaryote Crypthecodinium cohnii (Pyrrhophyta): two-dimensional electrophoresis and DNA-binding properties

Unlike typical eukaryotes, the Dinoflagellate Crypthecodinium cohnii does not contain histones but six major basic, low molecular weight nuclear proteins which represent only 10% of the DNA mass and differ from histones in their electrophoretic and DNA-binding properties. These proteins are resolved in two-dimensional electrophoresis (AUT-PAGE x SDS-PAGE). Three proteins with an apparent molecular mass of 16, 16.5 and 17 kDa (p16, p16.5 and p17) are present in addition to the major 14 kDa basic nuclear component (HCc). HCc itself is resolved in three proteins (alpha, beta and gamma). When the proteins are not reduced with 2-mercaptoethanol before 2D-PAGE, the migration of HCc alpha, beta and gamma is modified in a way which suggests the formation of both inter- and intramolecular disulfide bridges and thus, the presence of at least two cysteines. The amino-acid analysis of HCc proteins resolved in 2D gels confirms that they are lysine-rich. HCc alpha, beta and gamma as well as p16, p16.5 and p17 are removed from isolated chromatin with 0.6 M NaCl, indicating that their affinity for DNA in vivo is lower than that of core histones. Furthermore, in vitro, they bind more tightly to single-stranded than to double-stranded DNA.