The Intermolecular NOE Depends on Isotope Selection: Short Range vs Long Range Behavior.

The nuclear Overhauser effect (NOE) is a powerful tool in molecular structure elucidation, combining the subtle chemical shift of NMR and three-dimensional information independent of chemical connectivity. Its usage for intermolecular studies, however, is fundamentally limited by an unspecific long-ranged interaction behavior. This joint experimental and computational work shows that proper selection of interacting isotopes can overcome these limitations: Isotopes with strongly differing gyromagnetic ratios give rise to short-ranged intermolecular NOEs. In this light, existing NOE experiments need to be re-evaluated and future ones can be designed accordingly. Thus, a new chapter on intermolecular structure elucidation is opened.

Pheochromocytoma mimicking a non-ST elevation acute myocardial infarction.

We report a 57 year-old male patient admitted with a diagnosis of non-ST elevation acute myocardial infarction. He had suffered from chest pain, diaphoresis and intense asthenia for three days. The electrocardiogram on admission showed a high frequency sinus tachycardia. Troponin T levels were elevated. An echocardiogram suggested an antero-lateral myocardial infarction. Eventually, a left adrenal pheochromocytoma was discovered. Left ventricular function, severely depressed, returned to normal after medical and surgical therapy.

Usefulness of intrathoracic fluids accumulation monitoring with an implantable biventricular defibrillator in reducing hospitalizations in patients with heart failure: a case-control study.

BACKGROUND: The reduction of hospitalizations in patients with heart failure (HF) may have clinical and economical implications. MATERIALS AND METHODS: In a case-control study, we compared the number of hospital admissions for congestive HF during the same follow-up period in two homogeneous groups of patients, each consisting of 27 consecutive patients treated with biventricular pacing and back-up defibrillator (B-ICD) in our institution. The first group was implanted with an InSync Sentry, (Medtronic Inc, Minneapolis, MN, US), a B-ICD device with the OptiVol feature for monitoring intrathoracic fluid accumulation and equipped with an active acoustic alarm (Group 1); the second group was implanted with an InSync III Marquis (Medtronic), a B-ICD device with similar features except for the absence of the OptiVol (Group 2). Follow-up visits were performed at 3 month interval or in case of acoustic alarm. RESULTS: The patient clinical characteristics of the two groups were similar. In Group 1, with 359 +/- 98 days follow-up, 12 of the 27 patients, experienced 18 OptiVol alarms with only one hospital admission for congestive HF occurring in a patient who ignored the acoustic alarm for 13 days. In Group 2, eight HF hospitalizations occurred in seven patients (p < 0.05). CONCLUSIONS: The OptiVol feature is a useful tool for the clinical management of HF patients as it can result in early treatment during the pre-clinic stage of HF decompensation and in a significant reduction of hospital admissions for congestive HF.

Electrocardiographic abnormalities mimicking myocardial infarction in a patient with intracranial haemorrhage: a possible pitfall for prehospital thrombolysis.

The electrocardiogram, when applied in the prehospital setting, has a significant effect on a patient with chest pain. The potential effect includes both diagnostic and therapeutic issues, including the diagnosis of acute myocardial infarction and the indication for thrombolysis or invasive procedures. We report the case of a man who suffered from a syncope, with a prehospital electrocardiogram showing prominent ST-segment elevation. Out-of-hospital thrombolytic therapy was planned by the emergency department. Fortunately, thrombolysis did not start because the patient fared worse. He was taken to the emergency department and, because of mental status impairment, it was decided to perform a cranial computed tomographic scan. The diagnosis shifted to a haemorrhagic stroke. According to the guidelines, prehospital thrombolysis would have been inappropriate in this case because the patient did not have any chest discomfort. The pathophysiological mechanisms of electrocardiographic abnormalities in the setting of intracranial haemorrhage are reviewed, as well as the issue of thrombolysis administered or planned only on the basis of an electrocardiogram.

Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care.

OBJECTIVE: This study compared the effectiveness and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care in chronic heart failure (CHF) outpatients. BACKGROUND: Previous studies showed that about 50% of readmissions for CHF can be prevented by a multidisciplinary approach. However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management related to evidence-based medicine have not been considered. METHODS: A total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared. RESULTS: After 12 +/- 3 months of follow-up, the individual rate access in DH was 5.5 +/- 3.8 days. The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13 vs. 78, p < 0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed a cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 (CI $13,904 to $34,048). CONCLUSIONS: A heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients. This management strategy is cost-effective and has an equitable value from a societal point of view.