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In a nutshell, Thomas C. Neal’s Writing the Americas in Enlightenment Spain is a book about the nature and contours of the Spanish Enlightenment with a particular emphasis on the characteristics th...

Introduction: Attention-deficit/hyperactivity disorder (ADHD) and its comorbidities have an impact on the social anxiety of children and adolescents, but there are practically no studies addressing this topic in adolescence. Our objective was to assess the degree of social anxiety and to analyse the presence of psychiatric comorbidities (PSCs) in adolescents with ADHD. Methodology: We conducted a cross-sectional observational study in patients aged 12–18 years with a confirmed diagnosis of ADHD (DSM-5). We collected data on the presence and type of PSCs and assessed social anxiety by means of the Social Anxiety Scale for Adolescents (SAS-A). Results: Forty-six child and adolescent psychiatrists and paediatric neurologists participated in the study and recruited 234 patients. Of the total patients, 68.8% (159) were male and 31.2% (72) female, with a mean age in the sample of 14.9 years (95% CI, 14.6–15.1). The type of ADHD was combined type (C) in 51.7% (121), predominantly inattentive (PI) in 37.2% (87), and predominantly hyperactive-impulsive (PH) in 9% (21). Of all patients, 97.9% (229) received pharmacological therapy: 78.6% (184) methylphenidate, 15% (35) lisdexamfetamine and 4.3% (10) atomoxetine.We found PSCs in 50.4% of the patients (118), of which the most frequent were learning and communication disorders (20.1%, n = 47) and anxiety disorders (19.2%, n = 45). The patients scored significantly higher in the SAS-A compared to reference values in the healthy population. The scores in the SAS-A were less favourable in adolescents with the PI type compared to those with the PH type (P = .015). The presence of a comorbid anxiety disorder was associated with worst scores in SAS-A (P

ObjectiveTo investigate whether longer-term antibiotic treatment improves cognitive performance in patients with persistent symptoms attributed to Lyme borreliosis.MethodsData were collected during the Persistent Lyme Empiric Antibiotic Study Europe (PLEASE) trial, a randomized, placebo-controlled study. Study participants passed performance-validity testing (measure for detecting suboptimal effort) and had persistent symptoms attributed to Lyme borreliosis. All patients received a 2-week open-label regimen of intravenous ceftriaxone before the 12-week blinded oral regimen (doxycycline, clarithromycin/hydroxychloroquine, or placebo). Cognitive performance was assessed at baseline and after 14, 26, and 40 weeks with neuropsychological tests covering the cognitive domains of episodic memory, attention/working memory, verbal fluency, speed of information processing, and executive function.ResultsBaseline characteristics of patients enrolled (n = 239) were comparable in all treatment groups. After 14 weeks, performance on none of the cognitive domains differed significantly between the treatment arms (p = 0.49–0.82). At follow-up, no additional treatment effect (p = 0.35–0.98) or difference between groups (p = 0.37–0.93) was found at any time point. Patients performed significantly better in several cognitive domains at weeks 14, 26, and 40 compared to baseline, but this was not specific to a treatment group.ConclusionsA 2-week treatment with ceftriaxone followed by a 12-week regimen of doxycycline or clarithromycin/hydroxychloroquine did not lead to better cognitive performance compared to a 2-week regimen of ceftriaxone in patients with Lyme disease–attributed persistent symptoms.ClinicalTrials.gov identifierNCT01207739.Classification of evidenceThis study provides Class II evidence that longer-term antibiotics in patients with borreliosis-attributed persistent symptoms does not increase cognitive performance compared to shorter-term antibiotics.

Introduction/Objective Expectancies about symptom improvement or deterioration are reliable predictors of symptom progression and treatment outcomes (symptom resolution or symptomatic improvement) in many (non-)pharmacological studies and treatments. This study examined predictors of symptom improvement after antimicrobial therapy for persistent symptoms attributed to Lyme disease, hypothesizing particularly pre-treatment expectancies regarding symptom improvement to be predictive. Methods A predictive study was performed on pre-treatment and post-treatment individual characteristics, including expectancies, and physical and mental health–related quality of life (HRQoL) from the PLEASE-trial comparing randomized 12-weeks of doxycycline, clarithromycin-hydroxychloroquine, or placebo following 2 weeks of intravenous ceftriaxone. At end-of-treatment (14 weeks after trial start) and follow-up (52 weeks), complete data of 231 and 170 (of initial 280) patients with persistent symptoms temporally related to a history of erythema migrans or otherwise confirmed symptomatic Lyme disease, or accompanied by B. burgdorferi IgG or IgM antibodies, were examined through hierarchical regression analyses. Results In addition to pre-treatment HRQoL, pre-treatment expectancies regarding symptom improvement were consistently associated with stronger physical and mental HRQoL improvements at both end-of-treatment and follow-up (95% CI range: .09;.54, p p p = .003 to −7.34; −2.22, p Conclusions The present study shows that, next to pre-treatment functioning, patients’ pre-treatment and post-treatment expectancies regarding improvement of persistent symptoms attributed to Lyme disease relate to a more beneficial symptom course. Expectancies of patients may be relevant to explain and potentially improve patient outcomes (e.g., by optimized communication about treatment success). Trial registration ClinicalTrials.gov, NCT01207739 (Registration date: 23–09-2010) Key Points• As there is currently no sufficient symptom resolution or symptomatic improvement for many patients with persistent symptoms attributed to Lyme disease, it is relevant to know which factors determine symptom progression and predict heterogeneity in treatment response.• Next to pre-treatment functioning, expectancies regarding symptom improvement and having received antimicrobial study medication are associated with a more beneficial symptom course after both shorter-term and longer-term antimicrobial treatment.• Expectancies are relevant to consider in treatment studies and may be useful in clinical settings to improve symptom course and treatment outcome (e.g., by optimized communication about treatment success).

After implementing comercio libre (free internal trade) in 1778, the Spanish crown endeavored to create multiple new consulados (chambers of commerce) to facilitate commercial exchange within Spain's Atlantic territories. However, while the crown established new metropolitan consulados in the mid-1780s, it approved colonial consulados only in the 1790s, after the death of the minister of the Indies, José de Gálvez, in 1787. Why did the crown initially hesitate to establish colonial consulados? I argue that unlike Gálvez, who was committed to an extractive system of imperialism, the post-1787 ministers were inspired by a distinct kind of soft imperialism, which held that the empire's survival depended on stimulating colonial economic growth while promoting reciprocal bonds among all Spanish subjects. In reconstructing this history, I show how the post-1787 ministers established a new regime of colonial economic improvement to bind the empire during a moment of impending crisis.

Resumen Introduccion y objetivos La cirugia radioguiada es una tecnica de tratamiento quirurgico minimamente invasivo del hiperparatiroidismo primario. Los objetivos de este estudio fueron estudiar el porcentaje de exito de esta tecnica y realizar una comparacion de la misma con el estudio histologico intraoperatorio. Metodos Estudiamos retrospectivamente a 84 pacientes con hiperparatirodismo primario con gammagrafia paratiroidea positiva. Se administro una dosis de Tc-99 m sestamibi previa a la cirugia y se utilizo una sonda gammadetectora intraoperatoria para detectar el tejido paratiroideo anomalo, siguiendo la «regla del 20%». En todos los casos se realizo estudio anatomopatologico intraoperatorio y seguimiento clinico y analitico durante al menos 6 meses. Asimismo, se comparo el valor predictivo positivo de la ecografia cervical respecto a la gammagrafia paratiroidea. Resultados El porcentaje de exito de la cirugia radioguiada fue 99%. La sonda gammadetectora intraoperatoria tuvo una sensibilidad, especificidad, valores predictivos positivo y negativo respecto al estudio histologico intraoperatorio de 99, 73, 97 y 89%, respectivamente. La calcemia se normalizo en 83 de 84 pacientes (99%) y la paratohormona se normalizo en 77 de los 84 pacientes (92%). La ecografia mostro un bajo valor predictivo positivo (41%) comparada con la gammagrafia. Conclusiones La cirugia radioguiada es una tecnica con excelentes resultados en el tratamiento quirurgico minimamente invasivo del hiperparatiroidismo primario y podria sustituir tanto al estudio anatomopatologico intraoperatorio como a la determinacion intraoperatoria de paratohormona. Esta ultima posibilidad debe ser demostrada en futuros estudios.

Item does not contain fulltext FDG-PET/CT has proven its clinical value and cost-effectiveness in diagnosing metastatic infections in patients with Gram-positive bacteremia. In identification of metastatic foci, FDG-PET/CT is useful as a screening method when localizing symptoms are absent because it provides whole-body coverage. FDG-PET/CT detects early metabolic activity rather than the late anatomical changes as visualized by computed tomography and magnetic resonance imaging. FDG-PET/CT allows more precise localization of infection within a shorter time span between injection and diagnosis as compared to conventional nuclear imaging. This review focuses on the clinical application of imaging of metastatic infectious diseases, with an emphasis on FDG-PET/CT putting it in perspective with other imaging modalities.

Contains fulltext : 169925.pdf (Publisher’s version ) (Open Access) PURPOSE: The purpose of this study was to evaluate the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT scan) and magnetic resonance imaging (MRI) in diagnosing spondylodiscitis and its complications, such as epidural and paraspinal abscesses. METHODS: From January 2006 to August 2013 patients with a clinical suspicion of spondylodiscitis, with an infection, or with fever of unknown origin were retrospectively included if 18F-FDG-PET/CT and MRI of the spine were performed within a 2-week time span. Imaging results were compared to the final clinical diagnosis and follow-up data were collected. RESULTS: Sixty-eight patients were included of whom 49 patients were diagnosed with spondylodiscitis. MRI showed an overall sensitivity of 67 % and specificity of 84 %. Diagnostic accuracy was 58 %, when MRI was performed within 2 weeks after the start of symptoms and improved to 82 %, when performed more than 2 weeks after onset of symptoms. 18F-FDG-PET/CT showed a sensitivity of 96 % and a specificity of 95 %, with no relation to the interval between the scan and the start of symptoms. CONCLUSIONS: As compared to MRI, 18F-FDG-PET/CT has superior diagnostic value for detecting early spondylodiscitis. After 2 weeks both techniques perform similarly. 9 p.

Technological developments have encouraged the growth of various industries, which on the onehand can increase economic growth, but on the other hand, it can also cause environmentaldamage as a result of negative impacts resulting from waste generated. The coastal and marinewaters of Bitung City are industrial dense areas which are spread from the northern to thesouthern region. Besides that there were activitied which adding to the increasingly denseactivities in the coastal waters of Bitung City like the ferry port, cargo and container ports, andpassenger port. The research aims to analyze the level of pollution of mercury heavy metals(Hg), lead (Pb), and cadmium (Cd) in several types of fish consumption from Bitung waters; toget the dominant type of heavy metal exposed to fish meat; and determine the level of heavymetal contamination in the waters around Bitung based on bio-indicators.The results ofresearch showed that all fish samples were contaminated by heavy metals and each location forsampling levels of metal contamination based on bio-indicators was different, where the watersof Kampung Pisang have a higher level of metal contamination.

Revisionist historians have convincingly argued that Spanish American independence was not the result of simmering grievances that galvanised a national or Creole identity against Spain. Instead, this scholarship insists that Spanish American national identities did not exist at the time and that independence was an unforeseen process that must be understood in the context of the Napoleonic invasion of Iberia. But, if independence was undesirable before 1808 and if national identities arose at a latter period, how do we explain the early independence projects of ‘precursors’ like Juan Pablo Viscardo y Guzmán? By contextually reconstructing the logic behind Viscardo's projects, this article offers a new perspective on the intellectual conditions of possibility for Spanish American independence. It argues that though he certainly identified as a Creole from Peru, Viscardo actually deployed an Enlightenment global science of commerce, not Creole patriotism or nationalism, to legitimate Spanish American independence.

Introduction and objectives Radioguided surgery is a minimally invasive surgical technique for the treatment of primary hyperparathyroidism. The goals of our study were to evaluate the rate of success and compare the results with intraoperative histological analysis. Methods We retrospectively studied 84 patients with primary parathyroidism who had undergone radioguided surgery. All the patients had a positive parathyroid scintigraphy prior to surgery. An intravenous injection of Tc-99m sestamibi was administered before surgery, and radioguided location of the pathologic parathyroid tissue was performed using an intraoperative gamma probe, applying the “20% rule”. All resected specimens underwent intraoperative histologic analysis. All patients were followed up for at least 6 months. Positive predictive values of both parathyroid scintigraphy and cervical ultrasonography were also compared. Results Radioguided surgery success rate was 99%. Sensitivity, specificity, positive and negative predictive values for gamma probe were 99%, 73%, 97% and 89%, respectively. After surgery, 83 of 84 patients were eucalcaemic (99%) and parathyroid hormone normalised in 77 of 84 patients (92%). Ultrasonography showed low positive predictive value (41%) when compared with scintigraphy. Conclusions Radioguided surgery is a minimally invasive surgical technique with excellent results for the treatment of primary hyperparathyroidism and could replace both intraoperative histological analysis and intraoperative parathyroid hormone assay. Further studies are needed to confirm these findings.

Reseña de: Alimento, Antonella & Stapelbroek, Koen (eds.), The Politics of Commercial Treaties in the Eighteenth Century: Balance of Power, Balance of Trade, Palgrave, Macmillan, 2017, 472 pp., ISBN: 978-3-319-53574-6

Item does not contain fulltext PURPOSE: Early detection of infectious endocarditis is challenging. For diagnosing infectious endocarditis, the revised Duke criteria are the gold standard. Evidence of endocardial involvement on echocardiography is a major criterion, but sensitivity and specificity of echocardiography are not optimal. Here we investigated the utility of (18)F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) to diagnose infectious endocarditis in patients with gram-positive bacteraemia. METHODS: Seventy-two patients with gram-positive bacteraemia were prospectively included. Patients with a positive blood culture growing Staphylococcus aureus, Streptococcus species or Enterococcus species were eligible when a risk factor for developing metastatic infectious foci was present. Infectious endocarditis was defined according to the revised Duke criteria. All patients underwent (18)F-FDG PET/CT and echocardiography. (18)F-FDG uptake in or around the heart valves was evaluated independently by two nuclear medicine physicians. RESULTS: Sensitivity for diagnosing infectious endocarditis with (18)F-FDG PET/CT was 39% and specificity was 93%. The positive predictive value was 64% and negative predictive value was 82%. The mortality rate in patients without infectious endocarditis and without increased (18)F-FDG uptake in or around the heart valves was 18%, and in patients without infectious endocarditis but with high (18)F-FDG uptake in or around the heart valves the mortality rate was 50% (p = 0.181). CONCLUSION: (18)F-FDG PET/CT is currently not sufficiently adequate for the diagnosis of infectious endocarditis because of its low sensitivity. Improvements such as patient preparation with low carbohydrate-fat allowed diet and technical advances in the newest PET/CT scanners may increase sensitivity in future studies.

Purpose The purpose of this study was to evaluate the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT scan) and magnetic resonance imaging (MRI) in diagnosing spondylodiscitis and its complications, such as epidural and paraspinal abscesses. Methods From January 2006 to August 2013 patients with a clinical suspicion of spondylodiscitis, with an infection, or with fever of unknown origin were retrospectively included if 18F-FDG-PET/CT and MRI of the spine were performed within a 2-week time span. Imaging results were compared to the final clinical diagnosis and follow-up data were collected. Results Sixty-eight patients were included of whom 49 patients were diagnosed with spondylodiscitis. MRI showed an overall sensitivity of 67 % and specificity of 84 %. Diagnostic accuracy was 58 %, when MRI was performed within 2 weeks after the start of symptoms and improved to 82 %, when performed more than 2 weeks after onset of symptoms. 18F-FDG-PET/CT showed a sensitivity of 96 % and a specificity of 95 %, with no relation to the interval between the scan and the start of symptoms. Conclusions As compared to MRI, 18F-FDG-PET/CT has superior diagnostic value for detecting early spondylodiscitis. After 2 weeks both techniques perform similarly.

Item does not contain fulltext PURPOSE: Between 30 and 50% of febrile neutropenic episodes are accounted for by infection. C-reactive protein (CRP) is a nonspecific parameter for infection and inflammation but might be employed as a trigger for diagnosis. The aim of the study was to evaluate whether (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT can be used to detect inflammatory foci in neutropenic patients with elevated CRP and whether it helps to direct treatment. METHODS: Twenty-eight consecutive patients with neutropenia as a result of intensive chemotherapy for haematological malignancies or myeloablative therapy for haematopoietic stem cell transplantation were prospectively included. (18)F-FDG PET/CT was added to the regular diagnostic workup once the CRP level rose above 50 mg/l. RESULTS: Pathological FDG uptake was found in 26 of 28 cases despite peripheral neutrophil counts less than 0.1 x 10(-9)/l in 26 patients: in the digestive tract in 18 cases, around the tract of the central venous catheter (CVC) in 9 and in the lungs in 7 cases. FDG uptake in the CVC tract was associated with coagulase-negative staphylococcal bacteraemia (p < 0.001) and deep venous thrombosis (p = 0.002). The number of patients having Streptococcus mitis bacteraemia appeared to be higher in patients with grade 3 oesophageal FDG uptake (p = 0.08). Pulmonary FDG uptake was associated with the presence of invasive fungal disease (p = 0.04). CONCLUSION: (18)F-FDG PET/CT scanning during chemotherapy-induced febrile neutropenia and increased CRP is able to detect localized foci of infection and inflammation despite the absence of circulating neutrophils. Besides its potential role in detecting CVC-related infection during febrile neutropenia, the high negative predictive value of (18)F-FDG PET/CT is important for avoiding unnecessary diagnostic tests and therapy. 01 januari 2012

Contains fulltext : 95769.pdf (Publisher’s version ) (Closed access) Gram-positive bacteremia has a high morbidity and mortality rate of approximately 30%. Delayed diagnosis of clinically silent metastatic infectious foci is an important indicator for a complicated outcome. (18)F-FDG PET/CT allows detection of focal infection, resulting in lower relapse rates and mortality. Here, we present a cost-effectiveness analysis associated with introduction of (18)F-FDG PET/CT for patients with gram-positive bacteremia. METHODS: A cost-effectiveness analysis in a prospective (18)F-FDG PET/CT group (n = 115) and matched control group (n = 230) was performed alongside a clinical study, the results of which were previously published. Mortality at 6 mo was considered the final effect outcome and was used in the denominator of the incremental cost-effectiveness ratio. RESULTS: Mortality in the (18)F-FDG PET/CT group was 19%, compared with 32% in the control group (P < 0.01). Incremental costs of (18)F-FDG PET/CT were $9,454 (95% confidence interval [CI], $3,963-$14,947), mainly because of admission (mean, $6,631; 95% CI, $1,449-$11,814). Additional costs were related to echocardiography (P < 0.01), not to (18)F-FDG PET/CT (P = 0.8). The mean incremental costs of the (18)F-FDG PET/CT strategy estimated by stratification for endocarditis were $5,277 per patient (95% CI, $429-$10,123; P = 0.03). The point estimate of the incremental cost-effectiveness ratio is $72,487 per prevented death (95% CI, $11,388-$323,379). CONCLUSION: Introduction of a diagnostic regimen including routine (18)F-FDG PET/CT decreases morbidity and mortality. The cost increase is due to in-hospital treatment of metastatic infectious foci. Costs per prevented death, $72,487, are within the range that is considered to be efficient by Dutch guidelines. Patients with high-risk gram-positive bacteremia therefore should have easy access to (18)F-FDG PET/CT to enable early detection of metastatic infectious disease.

The effect of immediate incubation of blood cultures at 37°C on the turnaround time and the impact of Gram stain results on antimicrobial management were investigated. During a 6-month period, blood cultures collected at the emergency department outside laboratory operating hours were preincubated at 37°C until transportation to the laboratory. Upon the arrival of blood cultures at the laboratory, Gram stains and subcultures were made from all bottles prior to further incubation in the automated system (Bactec 9240). Data from 1 year earlier, when all blood cultures were stored at room temperature, were used for comparison. In the study period, 79 episodes of bacteremia were detected for 75 patients, compared to 70 episodes for 67 patients in the control period. Preincubation of blood cultures at 37°C resulted in a 15-h reduction in the median time to reporting of Gram stain results, from 34 to 19 h ( P

Objective To examine national estimates of forearm and wrist fractures among adults treated in US emergency departments. Methods The National Electronic Injury Surveillance System All Injury Program was used to estimate emergency department visits for unintentional fall related forearm and/or wrist fractures among adults aged 50 years or older between 2001 and 2007. Census population estimates were used as the denominator to calculate age-specific and age-adjusted fracture rates per 100 000 persons. Results Based on 14 771 cases, an estimated 1 045 008 adults aged ≥50 years were treated in US hospital emergency departments for fall related forearm and/or wrist fractures during the study period. Of these, an estimated 832 591 (80%) fractures occurred among women. The incidence of fractures among women increased gradually with age from the age of 50 years. In men, fracture rates remained low until later in life. Between 2001 and 2007, fracture rates increased predominantly among women in the age group 50–59 years at an annual rate of 3.9% (95% CI −0.1 to 8.2). Conclusions The study indicates marked gender differences in unintentional fall related forearm and/or wrist fractures among adults aged ≥50 years treated in US hospital emergency departments. Interventions aimed at preventing falls might be effective in reducing the incidence of this injury, particularly in those women who already have diminished bone mineral.

The treatment of persistent symptoms attributed to Lyme disease remains controversial. Recently, the PLEASE study did not demonstrate any additional clinical benefit of longer-term versus shorter-term antibiotic treatment. However, the economic impact of the antibiotic strategies has not been investigated. MethodsThis prospective economic evaluation, adhering a societal perspective, was performed alongside the PLEASE study, a multicenter, placebo-controlled, double-blind 1:1:1 randomized clinical trial in which all patients received open-label intravenous ceftriaxone for two weeks before the 12-week randomized blinded oral antibiotic regimen (doxycycline, clarithromycin plus hydroxychloroquine, or placebo). Between 2010 and 2013, patients (n = 271) with borreliosis-attributed persistent symptoms were enrolled and followed for one year. Main outcomes were costs, quality-adjusted life years, and incremental net monetary benefit of longer-term versus shorter-term antibiotic therapy. ResultsMean quality-adjusted life years (95% CI) were not significantly different (p = 0.96): 0.82 (0.77–0.88) for ceftriaxone/doxycycline (n = 82), 0.81 (0.76–0.88) for ceftriaxone/clarithromycin-hydroxychloroquine (n = 93), and 0.81 (0.76–0.86) for ceftriaxone/placebo (n = 96). Total societal costs per patient (95% CI) were not significantly different either (p = 0.35): €11,995 (€8,823-€15,670) for ceftriaxone/doxycycline, €12,202 (€9,572-€15,253) for ceftriaxone/clarithromycin-hydroxychloroquine, and €15,249 (€11,294-€19,781) for ceftriaxone/placebo. Incremental net monetary benefit (95% CI) for ceftriaxone/doxycycline compared to ceftriaxone/placebo varied from €3,317 (-€2,199-€8,998) to €4,285 (-€6,085-€14,524) over the willingness-to-pay range, and that of ceftriaxone/clarithromycin-hydroxychloroquine compared to ceftriaxone/placebo from €3,098 (-€888-€7,172) to €3,710 (-€4,254-€11,651). For every willingness-to-pay threshold, the incremental net monetary benefits did not significantly differ from zero. ConclusionThe longer-term treatments were similar with regard to costs, effectiveness and cost-effectiveness compared to shorter-term treatment in patients with borreliosis-attributed persistent symptoms after one year of follow-up. Given the results of this study, and taking into account the external costs associated with antibiotic resistance, the shorter-term treatment is the antibiotic regimen of first choice.

Contains fulltext : 53587.pdf (Publisher’s version ) (Closed access) Complicating infectious foci resulting from haematogenous or local spread of microorganisms are observed frequently in patients with Staphylococcus aureus bacteraemia (SAB) or Streptococcus species bacteraemia (SSB). The aim of this study was to compare the epidemiology of complicating infectious foci during SAB and SSB in a university hospital in The Netherlands. The charts of all adult patients diagnosed with SAB or SSB (except for Streptococcus pneumoniae bacteraemia) from July 2002 until December 2004 were reviewed retrospectively. Overall, 180 immunocompetent patients were identified, 127 with SAB and 53 with SSB. The percentage of patients with complicating infectious foci (39% of SAB patients, 25% of SSB patients) did not differ significantly between the groups. Endocarditis and cerebral involvement, however, were significantly more common in the SSB group. Of all complicating infectious foci, 32% lacked guiding signs or symptoms and 10% were detected only at autopsy. Factors associated with the development of complicating infectious foci were a delay in treatment for more than 48 h after the onset of symptoms, community acquisition, persistently positive blood cultures, congenital heart disease, and the presence of foreign bodies or prosthetic valves. Infection-related mortality was 18% in SAB patients and 11% in SSB patients and was significantly higher in patients with complicating infectious foci (29 vs. 9%). In conclusion, complicating infectious foci develop in approximately one-third of all patients with SAB and SSB. An active approach that entails searching for the complicating infectious foci is warranted in these patients, because only two-thirds of complicated infectious foci have guiding symptoms or signs, and infection-related mortality is significantly increased in patients with complicating infectious foci compared to patients without these infections. 9 p.

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Item does not contain fulltext Fever is a frequent complication of neutropenia induced by the treatment of various neoplasms. This is referred to as febrile neutropenia, which is considered to be a sign of a potentially life-threatening infectious complication until proven otherwise. However, most infectious foci do not have localizing signs and symptoms owing to the lack of inflammatory infiltrates during neutropenia. At the same time, recent studies also showed that febrile neutropenia is not a specific indicator for infection. An increase in C-reactive protein and fever may initially be caused by inflammation of the digestive tract mucosa due to cytotoxic treatment of hematologic malignancies. Infectious foci can be found in various organ systems, such as the respiratory tract including invasive fungal disease, septic thrombophlebitis in those patients with central venous catheters, metastatic infection including soft tissue abscesses, and the digestive tract, for example, colitis and esophagitis probably associated with mucosal barrier injury. A growing number of studies focus on the use of FDG-PET/CT to detect infection in patients with febrile neutropenia. Studies show that FDG uptake in inflammatory foci seems not to be hampered by the lack of circulating neutrophils. At the same time, the very high negative predictive value of FDG-PET/CT excluding localized infectious foci might facilitate guidance of antimicrobial treatment. However, larger prospective studies are needed before FDG-PET/CT would be embedded in diagnostic guidelines in patients with febrile neutropenia.

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Contains fulltext : 89699.pdf (Publisher’s version ) (Closed access) The timely detection of metastatic infectious foci in gram-positive bacteremia is crucial, because these foci often require prolonged antibiotic treatment or drainage. The diagnosis of metastatic infectious foci is difficult because localizing symptoms are often absent. We investigated whether (18)F-FDG PET/CT was able to detect such foci and whether detection influenced clinical outcome. METHODS: One hundred fifteen nonneutropenic patients with gram-positive bacteremia were prospectively included. Patients with positive blood cultures growing Staphylococcus aureus, Streptococcus species, or Enterococcus species were eligible when a risk factor for developing metastatic infectious foci was present. (18)F-FDG PET/CT was performed within 2 wk after the first positive blood culture. Abnormal (18)F-FDG uptake had to be confirmed by radiologic, microbiologic, or pathologic studies. Results were compared with a matched historical control group of 230 patients in whom no (18)F-FDG PET/CT was performed. RESULTS: Significantly more patients were diagnosed with metastatic foci in the study group (67.8% vs. 35.7%). Of the imaging investigations performed, (18)F-FDG PET/CT was the first to delineate infectious foci in 35 patients (30%). In the remaining 70%, either symptoms on physical examination or other imaging techniques first revealed infectious foci. The sensitivity, specificity, negative predictive value, and positive predictive value of (18)F-FDG PET/CT were 100%, 87%, 100%, and 89%, respectively. Relapse rates decreased from 7.4% to 2.6% among study patients (P = 0.09) and from 8.9% to 1.4% in patients with S. aureus (P = 0.04). Overall mortality after 6 mo decreased from 32.2% to 19.1% in the (18)F-FDG PET/CT group (P = 0.014). CONCLUSION: In the diagnostic work-up of high-risk patients with gram-positive bacteremia, (18)F-FDG PET/CT is a valuable technique that results in lower mortality rates. In patients with S. aureus bacteremia, relapse rates decreased significantly after the addition of (18)F-FDG PET/CT. 01 augustus 2010

Nuclear medicine techniques have a lot to offer in visualization of infectious and inflammatory foci. Quite often these techniques do not lead immediately to a definitive diagnosis, i.e., a histological or a microbiological diagnosis. However, they point to parts in the body where a particular metabolic process is ongoing, leading to elevated uptake of a radiopharmaceutical. With the help of other techniques, such as puncture, biopsy and culture, a definitive diagnosis can be obtained. In other words, scintigraphic imaging helps to elucidate the cause of the disease, and facilitates prompt installation of a tailored therapeutic regimen. Furthermore, with these techniques it is possible to monitor the effect of therapy.

The dialdehydes 1 and 11 obtained by periodate oxidation of methyl α- and β- d -glucopyranoside underwent cyclization with cyanoacetamide to give 3-deoxyhexopyranosides bearing a carbamoyl and a cyano group at C-3. Three products formed from 1 and were isolated as 4, 6-benzylidene acetals and found to have the α- d - gluco , α- d - manno , and β- l - gluco configurations. From 11 was obtained a normal cyclization product having the β- d - gluco configuration, its 4-methyl ether, and a 1:2 addition product.

Contains fulltext : 52019.pdf (Publisher’s version ) (Closed access) PURPOSE: Since (18)F-fluorodeoxyglucose (FDG) accumulates in neoplastic cells and in activated inflammatory cells, positron emission tomography (PET) with FDG could be valuable in diagnosing patients with fever of unknown origin (FUO). The aim of this study was to validate the use of FDG-PET as part of a structured diagnostic protocol in the general patient population with FUO. METHODS: From December 2003 to July 2005, 70 patients with FUO were recruited from one university hospital (n=38) and five community hospitals (n=32). A structured diagnostic protocol including FDG-PET was used. A dedicated, full-ring PET scanner was used for data acquisition. FDG-PET scans were interpreted by two staff members of the department of nuclear medicine without further clinical information. The final clinical diagnosis was used for comparison with the FDG-PET results. RESULTS: Of all scans, 33% were clinically helpful. The contribution of FDG-PET to the final diagnosis did not differ significantly between patients diagnosed in the university hospital and patients diagnosed in the community hospitals. FDG-PET contributed significantly more often to the final diagnosis in patients with continuous fever than in patients with periodic fever. FDG-PET was not helpful in any of the patients with normal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). CONCLUSION: FDG-PET is a valuable imaging technique as part of a diagnostic protocol in the general patient population with FUO and a raised ESR or CRP.

Contains fulltext : 50371.pdf (Publisher’s version ) (Closed access)

Contains fulltext : 50091.pdf (Publisher’s version ) (Closed access) Autoimmune phenomena after immune recovery due to HAART are not frequently described. Recently we found 3 patients with Graves' disease after starting HAART, outnumbering the expected incidence; 13 patients have been reported in the literature up to the present time.A probable relation between immune restoration and development of Graves' disease might be suspected.

Timely identification of metastatic complications of bloodstream infections due to spreading of the microorganisms to distant sites, although critical, is often difficult. As 18F-FDG accumulates in activated leukocytes in infectious lesions, 18F-FDG PET represents a promising imaging technique in these patients. The aim of this study was to assess the value of 18F-FDG PET in detecting infectious foci in patients at high risk of metastatic complications.The results of all 18F-FDG PET scans ordered because of suspected metastatic infection from October 1998 to September 2004 were analyzed retrospectively. These results were compared with conventional investigation techniques and the final clinical diagnosis.The results of 40 18F-FDG PET scans were evaluated. In 60% of all episodes, Gram-positive bacteria were cultured, in 18% Gram-negative bacteria, in 20% Candida spp., and in 3% the infection was polymicrobial. Metastatic complications were diagnosed in 75% of all episodes. A median number of 4 diagnostic procedures to search for metastatic infection had been performed before 18F-FDG PET was ordered. 18F-FDG PET diagnosed a clinically relevant new focus in 45% of cases and confirmed abnormalities already diagnosed in 30% of cases. The positive predictive value of 18F-FDG PET was 91% and the negative predictive value was 100%.18F-FDG PET is a valuable imaging technique in patients at high risk of metastatic infectious disease, even when the results of other diagnostic procedures are normal.

The prevalence of duodenal ulcer was studied in a rural area in Israel during a period of 5 yr. The mean, prevalence rate was 4.0%. Prevalence rates were related to age, sex, nativity groups, education, occupation, smoking habits, marital state, socio-economic state and presence of other diseases. A stepwise multiple regression analysis of all variables showed a very low positive association between the prevalence of duodenal ulcer and number of children, anxiety neurosis and smoking and a negative association with hypertension and Cochin and North-African origin. Single persons, males engaged in agricultural work and immigrants from Yemen and Kurdistan, had an increased prevalence rate of ulcer. However, none of these factors was significant when examined by a multiple regression equation. Eight out of 28 variables which were included in the multiple regression equation accounted for only 2.6% of total variance in the etiology of duodenal ulcer.

Hydroxylation of trans-1,3,4-trideoxy-5,6-O-isopropylidene-3-C-methyl- d -glycero-hex-3-enulose with osmium tetraoxide gave a mixture of 1-deoxy-5,6-O-isopropylidene-3-C-methyl- d -arabino- and - d -xylo-hexulose that was partially resolved by acetonation to give 1-deoxy-2,3:4,5-di-O-isopropylidene-3-C-methyl-β- d -fructopyranose (4), 1-deoxy-3,4:5,6-di-O-isopropylidene-3-C-methyl-keto- d -fructose (5), and 1-deoxy-2,3:4,6-di-O-isopropylidene-3-C-methyl-α- d -sorbofuranose (6). Treatment of a mixture of 4 and 5 with sodium borohydride gave, after column chromatography, 4 and 1-deoxy-3,4:5,6-di-O-isopropylidene-3-C-methyl- d -manno- and - d -gluco-hexitol. Deuterated derivatives corresponding to 4–6 were obtained when isopropylidenation was carried out with acetone-d6. Deacetonation of 4 and 5 yielded 1-deoxy-3-C-methyl- d -fructose, and 6 similarly afforded 1-deoxy-3-C-methyl- d -sorbose.

The reaction of α-(R)-methoxydiglycolaldehyde (1) with ethyl and tert-butyl cyanoacetate yielded methyl 2,4-di-O-acetyl-3-C-cyano-3-deoxy-3-ethoxycarbonyl-β- d -xylo- (4) and -α- l -xylo-pentopyranosides (5) (isolated as acetyl derivatives), and methyl 3-tert-butoxycarbonyl-3-C-cyano-3-deoxy-β- d -xylo- (6) and -α- l -xylo-pentopyranosides (7), respectively (1:1 addition products) (major products). The minor 1:2 addition products methyl 2-O-acetyl-3-tert-butoxycarbonyl-4-(1-tert-butoxycarbonyl-1-cyanomethyl)-3-C-cyano-3,4-dideoxy-α- l -lyxo- (12) and -α- l -xylo-pentopyranosides (13), and methyl 4-O-acetyl-3-tert-butoxycarbonyl-2-(1-tert-butoxycarbonyl-1-cyanomethyl)-3-C-cyano-2,3-dideoxy-β- d -xylo-pentopyranoside (14) were also isolated in the reaction of 1 with tert-butyl cyanoacetate followed by acetylation. Isomerizations were observed in the acetylation of 6 and 7, yielding methyl 2,4-di-O-acetyl-3-tert-butoxycarbonyl-3-C-cyano-3-deoxy-β- d -xylo- (8) and -α- l -arabino- (9), and -α- l -lyxo- (10) and -α- l -xylo-pentopyranosides (11), respectively. Methyl 2,4,6-tri-O-acetyl-3-C-cyano-3-deoxy-3-ethoxycarbonyl-α- d -gluco- (15), -α- d -manno- (16), and -β- l -gluco-hexopyranosides (17) together with 3,4-dideoxyhexopyranosides (18 and 19) (1:2 addition products) were isolated in the reaction of α-(S)-methoxy-α′-(R)-hydroxymethyldiglycolaldehyde (2) with ethyl cyanoacetate after acetylation. The same reaction using α-(R)-methoxy-α′-(R)-hydroxymethyldiglycolaldehyde (3) gave methyl 2,4,6-tri-O-acetyl-3-C-cyano-3-deoxy-3-ethoxycarbonyl-β- d -gluco-hexopyranoside (20) after acetylation. Reaction of 3 with tert-butyl cyanoacetate led to methyl 2,6-di-O-acetyl-3-tert-butoxycarbonyl-4-(1-tert-butoxycarbonyl-1-cyanomethyl)-3-C-cyano-3,4-dideoxy-β- d -gluco-hexopyranoside (21; 1:2 addition product) and methyl 2,4,6-tri-O-acetyl-3-tert-butoxycarbonyl-3-C-cyano-3-deoxy-β- d -gluco-hexopyranoside (22; 1:1 addition product), after acetylation.

Hydroxylation of ethyl cis-2,3-dideoxy-4,5-O-isopropylidene-2-C-methyl- dl -glycero-pent-2-enonate (1) with osmium tetraoxide gave ethyl 4,5-O-isopropylidene-β- dl -galactosaccharinate (ethyl 4,5-O-isopropylidene-2-C-methyl- dl -lyxonate, 3) and ethyl 4,5-O-isopropylidene-α- dl -glucosaccharinate (ethyl 4,5-O-isopropylidene-2-C-methyl- dl -ribonate, 4). Similarly, the trans-isomer of 1 yielded a mixture of ethyl 4,5-O-isopropylidene-α- dl -galactosaccharinate (ethyl 4,5-O-isopropylidene-2-C-methyl- dl -xylonate, 5) and ethyl 4,5-O-isopropylidene-β- dl -glucosaccharinate (ethyl 4,5-O-isopropylidene-2-C-methyl- dl -arabinonate, 6). Compounds 3–6 were transformed into the corresponding 1,4-lactones.

A case of pregnancy complicated by myocardial infarction and ventricular fibrillation treated with direct current defibrillation with fetal survival is presented.