Self-Assembly of Triblock Copolymers from Cyclic Esters as a Tool for Tuning Their Particle Morphology.

This paper presents the effect of end groups, chain structure, and stereocomplexation on the microparticle and nanoparticle morphology and thermal properties of the supramolecular triblock copolyesters. Therefore, the series of the triblock copolymers composed of l,l- and d,d-lactide, trimethylene carbonate (TMC), and ε-caprolactone (CL) with isopropyl ( iPr) or 2-ureido-4-[1 H]-pyrimidinone (UPy) end groups at both chain ends were synthesized. In addition, these copolymers were intermoleculary stereocomplexed by polylactide (PLA) blocks with an opposite configuration of repeating units to promote their self-assembly in various organic solvents. The combination of two noncovalent interactions of the end groups and PLA enantiomeric chains leads to stronger interactions between macromolecules and allows for alteration of their segmental mobility. The simple tuning of the copolymer microstructure and functionality induced the self-assembly of macromolecules at liquid/liquid interfaces, which consequently leads to their phase separation in the form of particles with diameters ranging from 0.1 µm to 10 µm. This control is essential for their potential applications in the biomedical field, where biocompatible and well-defined microparticles and nanoparticles are highly desirable.

The Life Care Center of St. Louis experience with subacute care.

The Life Care Center of St. Louis is a 100-bed, freestanding, subacute care facility. The major differences between subacute care facilities and nursing homes are described. The problems associated with dealing with medically complex conditions in a subacute care facility are stressed. The center's approach to rehabilitation is reviewed in detail. The utility of the Functional Independence Measure in subacute care settings is discussed. Common conditions seen in subacute care facilities are briefly reviewed.

[Results of cervix neoplasm prophylaxis in women examined during the health promotion program in the Central Railway Hospital]. / Wyniki profilaktyki raka szyjki macicy u kobiet badanych w programie promocji zdrowia w Centralnym Szpitalu Kolejowym.

In the program of cervical cancer prophylaxis in CRH in 1997 simultaneous cytology and colposcopy evaluation of the uterine cervix were performed. Among 1479 women examined there were 6 cases (0.4%) of CIN 3, 34 cases (2.79%) of CIN 1 and CIN 2 and no case of invasive cervical cancer. The results of these studies point at high effectiveness of simultaneous use of colposcopy and cytology as complementary methods in prophylaxis of cervical cancer.

Neuromuscular blockade after ingestion of tree tobacco (Nicotiana glauca).

Two patients presented with life-threatening motor paresis after ingestion of leaves from the tree tobacco plant (Nicotiana glauca ). In addition to severe muscle weakness, bulbar palsies, flexor muscle spasm, hypertension, nausea, vomiting, and respiratory compromise were reported or observed. These are the fourth and fifth reported cases of a toxicologic emergency apparently caused by the alkaloid, anabasine, an isomer of nicotine found in the tobacco tree plant. The effects of this plant ingestion can mimic other better-known causes of paresis or paralysis. In areas of the country where the plant is indigenous, this toxicologic condition should be considered in the differential diagnosis of patients presenting with paresis or paralysis.

Effect of antibiotic treatment on vegetation size and complication rate in infective endocarditis.

BACKGROUND: Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction, and with congestive heart failure. Embolic events are more common in patients with echocardiographically discernible vegetations, especially when vegetations are > 10 mm in diameter. HYPOTHESIS: The objective of the study was to follow vegetation morphology during native valve endocarditis, to compare it with the clinical course and antibiotic treatment chosen, and to evaluate whether the impact on vegetation size and complication rate of antibiotic regimens differed in patients with positive and negative blood cultures. METHODS: The effect of different antibiotic regimes on vegetation size monitored by using transesophageal echocardiography was evaluated in 183 patients with echocardiographic evidence of infective endocarditis. A total of 223 vegetations attached to the aortic or mitral valves were detected using the transesophageal approach. The patients were followed for a mean of 76 weeks and underwent a minimum of two consecutive transesophageal echocardiographic examinations. RESULTS: Treatment with different kinds of antibiotics corresponded with significant differences in vegetation size; vancomycin-associated treatment was related to a 45% reduction, ampicillin to a 19% reduction, penicillin to a 5% reduction, penicillase-resistant drugs to a 15% increase, and cephalosporin to a 40% increase in vegetation size. Multivariate analysis showed that penicillin, cephalosporin, and penicillase-resistant drug treatments were associated with an increased embolic risk, vancomycin treatment with abscess formation, and cephalosporin medication with increased mortality. Plotting changes in vegetation size against the incidence of embolism and mortality, linear regression analysis suggested a 40-50% reduction in vegetation size, thereby greatly reducing the risk of embolism and mortality. CONCLUSION: Our study shows that different antibiotics have different effects on vegetation size. The highest complication rate was observed when vegetations significantly increased in size during antibiotic treatment. Especially in culture-negative patients, monitoring vegetation size by means of transesophageal echocardiography may prove to be useful for estimating the efficacy of antibiotic treatment.

[Reliability of digital transesophageal echocardiography in imaging the left coronary artery]. / Zuverlässigkeit der digitalen transösophagealen Echokardiographie in der Darstellung der linken Herzkranzarterie.

Fifty consecutive patients (mean age 56 years) were examined to evaluate the reliability of transesophageal echocardiography in the evaluation of the left proximal coronary artery. Results of 28 cases were compared to selective coronary angiography. Echocardiography was able to visualize the left main artery for the length of 1.0 +/- 0.6 cm in all patients (100%), the left circumflex artery for maximal 3.1 +/- 1.4 cm in 86% and the left anterior descending artery as long as 2.3 +/- 0.9 cm in 58%. The intraluminal diameter of the most proximal localized segments measured by echocardiography and angiography in the LAO and RAO-projection was in terms of the left main artery 4.1 +/- 0.9 mm, 4.1 +/- 0.9 mm and 4.0 +/- 0.9 mm (n.s.), of the left circumflex artery 2.8 +/- 0.5 mm, 3.3 +/- 0.8 mm and 3.3 +/- 0.9 mm (n.s.) and of the left anterior descending artery 3.0 +/- 0.8 mm, 3.4 +/- 0.7 mm, and 3.6 +/- 1.0 mm (n.s.). In respect of detection of coronary artery stenoses in correspondence to the coronary angiogram sensitivity was 81%, specificity 93% and positive predictive accuracy 86%. Quantitative analyses of the coronary anatomy and the correlation to angiography could contribute to the validation of transoesophageal echocardiography.

Three-dimensional imaging of cardiac mass lesions by transesophageal echocardiographic computed tomography.

Three-dimensional echocardiography is a new imaging technique that allows more realistic visualization of cardiac morphology. This study presents data about the diagnostic potentials of this technique concerning cardiac mass lesions, as well as its feasibility in clinical application. After the conventional investigation, multiple cross-sectional images were obtained during automatic forward advancement of a monoplane transducer mounted on a transesophageal probe. Three-dimensional reconstruction and volume determination were performed off line. Twenty-four patients were studied. In 14 cases results of echocardiographic computed tomography (echo-CT) were compared with those of monoplane/biplane transesophageal echocardiography. In 23 patients a conventional transesophageal investigation with the echo-CT probe and in 20 patients tomographic scanning were possible. Data acquisition required 12 +/- 4 minutes and three-dimensional reconstruction required 35 +/- 14 minutes. In 13 patients mass lesions were found; in 11 of 13 patients echo-CT provided diagnostic information about the precise spatial orientation and morphology of cardiac structures that could not be obtained by monoplane/biplane transesophageal echocardiography. The technique revealed accurate distance measurements and volume determination of mass lesions. Echo-CT is a further step toward the application of clinically useful three-dimensional echocardiography.

[Multi-plane transesophageal echocardiography--the next step to 3 dimensional imaging of the heart]. / Wieloplaszczyznowa echokardiografia przezprzelykowa--kolejny krok do trojwymiarowej oceny serca.

The multiplane transesophageal echocardiography (MTEE) is a new method making the precise imaging of the heart and great vessels possible. That technique allows to obtain the images of cardiovascular structures in two perpendicular investigation planes ("biplane" operation): transverse (examination angle is equal to 90 degrees--in relation to long axis of esophagus) and longitudinal = sagittal (examination angle is equal to 0 degree--in relation to long axis of esophagus) and, as well, in all medial planes enclosed from 0 degree to 90 degrees examination angle. During the investigation planes were being rotated mechanically or manually by rotation wheel. Passing from one plane to another is fluent, due to that the heart and main vessels can be observed continuously. Sector angle variability is 180 degrees (from minus 90 degrees to plus 90 degrees). The investigation planes from 0 degrees to plus 90 degrees from so called "normal" visualization field, and planes from 90 degrees to 0 degree make a "mirror" reflection of the "normal" field (mirror field). In our investigations the Vingmed-Sonotron echocardiograph connected with 5 MHz annular phased--array transducer, placed at the end of flexible endoscope was used. The multiplanar transducers have a full Doppler option (pulsed and continuous waves) with the possibility of colour flow imaging. The initial experience with the new method is presented in this report. The MTEE enables precise assessment of atrial septal defects. The multiplane imaging allows complete evaluation of heart muscle thickness and left ventricular contractility. This technique gives a better visualization of coronary artery. MTEE permits for planimetric assessment of aortic valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Two-dimensional transesophageal echocardiography (clinical value)]. / Dwuplaszczyznowa echokardiografia przezprzelykowa (wartosc kliniczna).

The introduction of two-dimensional echocardiography (echo 2D) complemented by doppler techniques has allowed to assess the dynamic function of the heart. However in 10-15% patients the standard transthoracic method (TEE) does not provide complete echocardiographic image due to obesity, emphysema and deformations of thorax. These difficulties have been later overcome by transesophageal probe, but it made the examination possible only in one plane-monoplane TEE (m-TEE). Transesophageal echocardiography the biplane probe (bi-TEE), introduced in late 80s has permitted the heart and aorta visualization in two perpendicular planes: transverse (T) and longitudinal (L). The purpose of our study was to establish the diagnostic value of biplane transesophageal echocardiography in comparison with hitherto existing monoplane echocardiography (transverse plane). The study group consists of 60 patients (aged 19-78 years) with various diseases of heart and aorta. We performed biplane transesophageal examinations with the use of Aloka SSD-870 echocardiograph connected with the biplane probe (45 patients) or new, prototypical matrix probe (15 patients). For the heart and aorta assessment the typical projections were used. The advantages of biplane TEE compared with monoplane TEE are as follows: 1) more favorable left ventricular examination, 2) better assessment of the heart apex, 3) the ability to investigate the right heart; tricuspid valve, right ventricular outflow tract, pulmonary valve, pulmonary trunk and right pulmonary artery, 4) precise imaging of both atrial' structures: cavities, intraatrial septum, foramen ovale, left atrial appendage, venae cavae and pulmonary veins, 5) possibility of thoracic aorta diagnostics, especially in ascending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis.

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

Spontaneous echo contrast imaging in infective endocarditis: a predictor of complications?

Infective endocarditis is associated with significant morbidity and mortality. Valvular destruction and congestive heart failure are more common in patients with echocardiographically detectable vegetations. In addition, spontaneous platelet aggregation is increased when vegetations are present on cardiac valves. The aim of the study was to assess the prognostic value of spontaneous echo contrast (SEC) imaging, as SEC is supposed to reflect red blood cell aggregates stimulated by platelet activity. We studied 293 patients with clinical signs of infective endocarditis. Vegetations, attached to the aortic or mitral valve, were found in 130 patients (44.4%) who were followed for a mean period of 12 months. In 34 of these 130 patients (26.2%) SEC was imaged during the initial transesophageal echocardiographic examination. In these patients SEC indicated a prolonged healing of infective endocarditis with a specificity of 91.2%, a sensitivity of 77.3%, a positive accuracy of 77.3%, a negative accuracy of 74.3%. Multivariate analysis revealed that SEC is a risk factor for valve replacement (p less than 0.001) and for embolic events (p less than 0.001), less for mortality (p less than 0.01), and lowest for abscess formation (p less than 0.05). The dose of ADP to induce half-maximal platelet aggregation was significantly lower in patients with SEC (0.71 +/- 0.15 microliters) than without SEC (1.05 +/- 0.12 microliters; p less than 0.05), implying an increased spontaneous platelet aggregation in the presence of SEC. Our data provide evidence that systemically activated coagulation plays an important role in infective endocarditis. SEC, the echocardiographic implication of an increased platelet aggregation, predicts complications such as thromboembolic events and the need for surgery and is closely related to the prolonged healing period of infective endocarditis. In addition to demonstrating vegetations, transesophageal echocardiography provides information helpful in assigning patients to a high-risk subgroup. Transesophageal echocardiography may play an important role in assessing the clinical outcome of these patients.

Identification of abscess formation in native-valve infective endocarditis using transesophageal echocardiography: implications for surgical treatment.

The object of the study was to follow patients with endocarditis-associated abscesses in order to evaluate the clinical outcome with and without surgical intervention. Transesophageal echocardiography successfully displayed the location and extent of abscess cavities in 14 patients (group A) with aortic valve endocarditis. The infective process was limited to the perivalvular tissue in two, extended into the ascending aorta in six, and included the interventricular septum, the right ventricular outflow tract, interatrial septum, and/or mitral valve annulus in six patients. The complication rate was significantly higher in group A than in group B, which consisted of 27 patients with proven signs of endocarditis but without endocarditis-associated abscesses. The complication rates were embolic events 64.3% in group A vs 29.6% in group B, need for surgery in 64.3% vs 18.5%, and death in 50.0% vs 3.7%, respectively. The duration of fever--as a marker of an active infective process--before diagnosis and the onset of adequate treatment was significantly higher in group A than in group B (46.7 +/- 8.4 days vs 7.7 +/- 2.6 days). Organisms were isolated in 71.4% in group A and in all patients of group B. Streptococcal infections were noted in A in 54.5% vs 44.4% in B., staphylococcal in 27.3% vs 40.7%. Initial surgical repair in 9 of 14 patients in A (64.3%) included nine aortic valve and one mitral valve prosthesis implantations, two aortic valve-annulus reconstructive procedures, one dacron patch closure, and three partial resections of the aorta ascendens with end-to-end anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size.

The diagnostic value of transesophageal echocardiography in monitoring the clinical course has been evaluated in 83 patients with echocardiographic evidence of infective endocarditis. A total of 103 vegetations attached to the aortic or mitral valves were detected by use of the transesophageal approach. The patients were monitored for a mean of 74 weeks and underwent a minimum of two consecutive transesophageal echocardiographic examinations. Group A included patients with increasing or remaining constant size of vegetation (8.2 +/- 1.5 to 11.2 mm, p less than 0.05) during 4 to 8 weeks of antimicrobial therapy, whereas group B was formed by patients with decreasing vegetation size (8.3 +/- 0.8 to 4.9 +/- 0.8 mm, p less than 0.05). The incidences of complications after diagnosis and onset of therapy was higher in group A than in group B: valve replacement (45% versus 2%, p less than 0.05), embolic events (45% versus 17%, p less than 0.05), perivalvular abscess formation (13% versus 2%, p less than 0.05), and mortality (10% versus 0%, respectively, p less than 0.05). Staphylococcus aureus was the most frequent organism isolated in group A (44% versus 11% in B, p less than 0.05) and Streptococcus viridans in group B (33% versus 18% in A, p less than 0.05). Blood cultures were negative in nearly 50% of the patients in each group. There was no difference in the incidences of complications in patients with positive or negative blood cultures. We conclude that an increase in vegetation size during antibiotic therapy predicts a prolonged healing phase of infective endocarditis. This prolonged healing period is associated with a significantly increased risk of complications, independent of blood culture results. Monitoring vegetation size contributes important information concerning prognosis and stage of risk, and it aids in the choice of patient management in infective endocarditis. Because embolic events after diagnosis and onset of treatment are less frequent in rapid-healing endocarditis, surgery cannot be recommended to prevent further events taking into account the high risk of surgery.