Streamlined Catalytic Enantioselective Synthesis of α-Substituted ß,γ-Unsaturated Ketones and Either of the Corresponding Tertiary Homoallylic Alcohol Diastereomers.

A widely applicable, practical, and scalable strategy for efficient and enantioselective synthesis of ß,γ-unsaturated ketones that contain an α-stereogenic center is disclosed. Accordingly, aryl, heteroaryl, alkynyl, alkenyl, allyl, or alkyl ketones that contain an α-stereogenic carbon with an alkyl, an aryl, a benzyloxy, or a siloxy moiety can be generated from readily available starting materials and by the use of commercially available chiral ligands in 52-96% yield and 93:7 to >99:1 enantiomeric ratio. To develop the new method, conditions were identified so that high enantioselectivity would be attained and the resulting α-substituted NH-ketimines, wherein there is strong C═N → B(pin) coordination, would not epimerize before conversion to the derived ketone by hydrolysis. It is demonstrated that the ketone products can be converted to an assortment of homoallylic tertiary alcohols in 70-96% yield and 92:8 to >98:2 dr-in either diastereomeric form-by reactions with alkyl-, aryl-, heteroaryl-, allyl-, vinyl-, alkynyl-, or propargyl-metal reagents. The utility of the approach is highlighted through transformations that furnish other desirable derivatives and a concise synthesis route affording more than a gram of a major fragment of anti-HIV agents rubriflordilactones A and B and a specific stereoisomeric analogue.

Valor prognóstico da disfunção ventricular diastólica em pacientes com sepse grave e choque séptico / Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock

RESUMO Objetivo: Avaliar a prevalência de disfunção miocárdica e seu valor prognóstico em pacientes com sepse grave e choque séptico. Métodos: Pacientes sépticos adultos, admitidos em uma unidade de terapia intensiva, foram estudados de forma prospectiva por meio de ecocardiografia transtorácica dentro das primeiras 48 horas após sua admissão e, então, entre o sétimo e o décimo dias. As variáveis ecográficas de função biventricular, inclusive a relação E/e', foram comparadas entre sobreviventes e não sobreviventes. Resultados: Foi realizado um total de 99 ecocardiogramas (53 na admissão e 46 entre os dias 7 e 10) em 53 pacientes com média de idade de 74 anos (desvio padrão de 13 anos). Estava presente disfunção sistólica em 14 (26%); disfunção diastólica foi observada em 42 (83%) pacientes; e ambos os tipos de disfunção estavam presentes em 12 (23%) pacientes. A relação E/e', ou índice de disfunção diastólica, foi o melhor preditor de mortalidade hospitalar segundo a área sob a curva ROC (0,71) e se constituiu em um preditor independente do desfecho, conforme determinado pela análise multivariada (odds ratio - OR = 1,36 [1,05 - 1,76]; p = 0,02). Conclusão: Em pacientes sépticos admitidos em uma unidade de terapia intensiva, a disfunção sistólica determinada ecograficamente não se associa com aumento da mortalidade. Em contraste, a disfunção diastólica foi um preditor independente do desfecho.

ABSTRACT Objectives: To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. Methods: Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. Results: A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). Conclusion: In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome.

Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock.

OBJECTIVES: To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. METHODS: Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. RESULTS: A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). CONCLUSION: In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome.