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Administration of positively charged amino acids has been introduced to reduce the nephrotoxicity of targeted radiopeptide therapy (TRT). However, the amino acid solution may have side effects, including hyperkalaemia. The aim of this study was to evaluate the frequency and the magnitude of hyperkalaemia in neuroendocrine tumour (NET) patients undergoing TRT.Enrolled in the study were 31 patients with NET eligible for TRT with [(90)Y-DOTA(0),Tyr(3)]octreotide ((90)Y-DOTATOC). Their mean age was 54 ± 14 years. Of these 31 patients, 21 (67%) were referred for the first treatment cycle, while 10 (33%) were referred for a subsequent therapy cycle. Patients were treated with therapeutic doses of (90)Y-DOTATOC ranging from 7,030 to 35,520 MBq. To inhibit tubular reabsorption of (90)Y-DOTATOC, 1 l of physiological saline solution containing 25 g of arginine hydrochloride and 25 g of lysine hydrochloride was given over 4 h starting 1 h before (90)Y-DOTATOC injection. All patients underwent a standard biochemical blood analysis at baseline, and 4 h and 24 h after the beginning of the amino acid infusion.ANOVA repeated measures showed a significant overall effect on K(+) levels over time (F = 118.2, df = 2, P0.0001). Mean serum levels of K(+) were 4.00 ± 0.33 mmol/l at baseline, 5.47 ± 0.57 mmol/l at 4 h, and 4.38 ± 0.63 mmol/l at 24 h after the beginning of the infusion. Post-hoc analysis showed that K(+) levels at 4 h were significantly (P0.05) higher than at baseline. K(+) levels at 24 h were significantly (P0.05) lower than at 4 h but they were still significantly (P0.05) higher than K(+) levels at baseline. On a subject-by-subject basis, none of the 31 patients had increased K(+) levels at baseline. At 4 h, 24 of the 31 patients (77%) had K(+) levels above the normal range, and 6 patients (19%) experienced severe hyperkalaemia (K(+) ≥ 6 mmol/l). All patients with increased K(+) levels were clinically asymptomatic. At 24 h, only 4 patients (13%) had increased K(+) serum levels. The magnitude of the increase in K(+) levels between baseline and 4 h was relatively homogeneous over the whole group (1.41 ± 0.50 mmol/l) and it was not related (linear regression, P0.05) to baseline K(+) levels. Intravenous administration of 40 mg furosemide 1 h after the beginning of the amino acid infusion did not have a significant effect on K(+) levels (P0.05). No clinical characteristic was predictive for the increase in K(+) levels (chi-squared test, P0.05).Hyperkalaemia is a frequent, potentially life-threatening side effect of basic amino acid infusion during TRT. K(+) levels 4 h after the beginning of the infusion should be monitored in patients at risk of complications, such as those with heart disease and those with risk factors for nephrotoxicity.

Aims Several high-sensitivity cardiac troponin (hs-cTn) assays have recently been developed. It is unknown which hs-cTn provides the most accurate prognostic information and to what extent early changes in hs-cTn predict mortality. Methods and results In a prospective, international multicentre study, cTn was simultaneously measured with three novel [high-sensitivity cardiac Troponin T (hs-cTnT), Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI, Siemens] and a conventional assay (cTnT, Roche Diagnostics) in a blinded fashion in 1117 unselected patients with acute chest pain. Patients were followed up 2 years regarding mortality. Eighty-two (7.3%) patients died during the follow-up. The 2-year prognostic accuracy of hs-cTn was most accurate for hs-cTnT [area under the receivers operating characteristic curve (AUC) 0.78 (95% CI: 0.73–0.83) and outperformed both hs-cTnI (Beckman-Coulter, 0.71 (95% CI: 0.65–0.77; P = 0.001 for comparison), hs-cTnI (Siemens) 0.70 (95% CI: 0.64–0.76; P < 0.001 for comparison)] and cTnT 0.67 (95% CI: 0.61–0.74; P < 0.001 for comparison). Absolute changes of hs-cTnT were more accurate than relative changes in predicting mortality, but inferior to presentation values of hs-cTnT. Combining changes of hs-cTnT within the first 6 h with their presentation values did not further improve prognostic accuracy. Similar results were obtained for both hs-cTnI assays regarding the incremental value of changes. Hs-cTn concentrations remained predictors of death in clinically challenging subgroups such as patients with pre-existing coronary artery disease, impaired renal function, and patients older than 75 years. Conclusion High-sensitivity cardiac Troponin T is more accurate than hs-cTnI in the prediction of long-term mortality. Changes of hs-cTn do not seem to further improve risk stratification beyond initial presentation values.

Aims To examine the diagnostic accuracy of sensitive cardiac troponin (cTn) assays in elderly patients, since elevated levels with sensitive cTn assays were reported in 20% of elderly patients without acute myocardial infarction (AMI). Methods and results In this multi-centre study, we included 1098 consecutive patients presenting with symptoms suggestive of AMI, 406 (37%) were >70 years old. Measurement of three investigational sensitive cTn assays [Roche high-sensitive cTnT (hs-cTnT), Siemens cTnI-Ultra, and Abbott-Architect cTnI) and the standard assay (Roche cTnT) was performed in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists. Acute myocardial infarction was the adjudicated final diagnosis in 24% of elderly patients. Among elderly patients without AMI, baseline cTn levels were elevated above the 99th percentile in 51% with Roche hs-cTnT, in 17% with Siemens TnI-Ultra, and 13% with Abbott-Architect cTnI. The diagnostic accuracy as quantified by the area under the receiver operating characteristic (ROC) curve (AUC) was significantly greater for the sensitive cTn assays compared with the standard assay (AUC for Roche hs-cTnT, 0.94; Siemens cTnI-Ultra, 0.95; and Abbott-Architect cTnI, 0.95 vs. AUC for the standard assay, 0.90; P < 0.05 for comparisons). The best cut-offs for the sensitive cTn-assays determined by the ROC-curve in elderly patients differed clearly from those in younger patients. Furthermore, the prognostic value regarding 90-day mortality varied among the sensitive cTn assays. Conclusion Sensitive cTn assays have high diagnostic accuracy also in the elderly. Mild elevations are common in elderly non-AMI patients, therefore the optimal cut-off levels are substantially higher in elderly as compared with younger patients. Furthermore, sensitive cTn assays yielded different prognostic value (ClinicalTrials.gov number, [NCT00470587][1]). [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00470587&atom=%2Fehj%2Fearly%2F2011%2F02%2F28%2Feurheartj.ehr033.atom

Endothelial dysfunction plays a major role in cardiovascular diseases, including acute myocardial infarction (AMI). However, its quantification has not been available as a clinical tool.In a prospective international multicentre study, we analyzed the diagnostic and prognostic utility of endothelial dysfunction as quantified by C-terminal proendothelin-1 (CT-proET-1) in 658 consecutive patients presenting with suspected AMI. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long-term for mortality.The adjudicated final diagnosis was AMI in 145 patients (22%). The diagnostic performance of CT-proET-1 for AMI was moderate; its area under the receiver operating characteristic (ROC) curve amounted to 0.66 (95% confidence interval [CI], 0.61-0.72; P0.001). There was no significant increase in the AUC when CT-proET-1 was added to either cardiac troponin T (cTnT) or high-sensitivity cTnT (hs-cTnT). Seventy four percent of patients who died during the first 24 months (n = 50) were in the fourth quartile of the CT-proET-1 presentation value (82 pmol/L). The prognostic accuracy of CT-proET-1 regarding mortality was tantamount to that of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and outperformed cTnT and hs-cTnT both in patients with AMI and in patients without acute coronary syndrome. CT-proET-1 at presentation yielded high prognostic accuracy that was similar to that of the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores. The TIMI risk score could be significantly improved by adding CT-proET-1 (integrated discriminatory improvement [IDI] of 0.074 P = 0.004).Use of CT-proET-1 improves risk stratification of unselected patients with suspected AMI. CT-proET-1 did not provide additional diagnostic value.

Background Concerns have been raised about possible gender disparities in cardiac investigations and/or outcome. This study sought to examine and compare the diagnostic and prognostic performance of selected cardiac biomarkers in women versus men. Methods In a prospective, multicenter cohort of patients with acute chest pain cardiac troponin T (cTnT) (fourth-generation Roche assay), high-sensitivity cTnT (hs-cTnT), and copeptin were measured at presentation. Results Of 1,247 patients, 420 were women and 827 were men. Although the rate of acute myocardial infarction was similar in women (14.5%) and men (16.6%, P = .351), women more frequently had cardiac but noncoronary causes of chest pain (17.4% vs 10.8%, P = .001) and less frequently had unstable angina (8.8% vs 16.6%, P = .002) than men. Diagnostic accuracy as quantified by the area under the receiver operating characteristic curve (AUC) for acute myocardial infarction in women was 0.90 (95% CI 0.84-0.95) for cTnT, which was lower than the AUC for hs-cTnT alone (0.94, 95% CI [0.91-0.98]), the combination of cTnT with copeptin (0.96, 95% CI [0.94-0.98]) or the combination of hs-cTnT with copeptin (0.96, 95% CI [0.93-0.98]) ( P = .008, P = .006, and P = .002, respectively). Prognostic accuracy as quantified by the AUCs for 1-year mortality was 0.69 (0.56-0.83), 0.86 (0.79-0.93), 0.87 (0.81-0.94), and 0.87 (0.80-0.94), respectively. No relevant gender differences in AUCs were observed. Conclusion The diagnostic and prognostic performance of cTnT, hs-cTnT, and copeptin is as good in women as in men. High-sensitivity cTnT and the combination of cTnT and copeptin outperform cTnT alone, both in women and men.

Background: Hypoxia precedes cardiomyocyte necrosis in acute myocardial infarction (AMI). We therefore hypothesized that uric acid as a marker of oxidative stress and hypoxia might be useful in the early diagnosis and risk stratification of patients with suspected AMI. Materials and methods: In this prospective observational study uric acid was measured at presentation in 892 consecutive patients presenting to the emergency department with suspected AMI. The final diagnosis was adjudicated by two independent cardiologists. Patients were followed 24 months regarding mortality. Primary outcome was the diagnosis of AMI secondary outcome was short and long term mortality. Results: Uric acid at presentation was higher in patients with AMI than in patients without (372 µM vs. 336 µM; P < 0·001). The diagnostic accuracy of uric acid for AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0·60 (95Cl 0·56 0·65). When added to cardiac troponin T (cTnT) uric acid significantly increased the AUC of cTnT from 0·89 (95Cl 0·85 0·93) to 0·92 (95Cl 0·89 0·95 P = 0·020 for comparison). Cumulative 24 month mortality rates were 2·2 in the first 5·4 in the second and the third and 15·6 in the fourth quartile of uric acid (P < 0·001 for log rank). Uric acid predicted 24 month mortality independently. Adding uric acid to TIMI and GRACE risk score improved their prognostic accuracy as shown by an integrated discrimination improvement of 0·04 (P = 0·007) respective 0·02 (P = 0·021). Conclusions: Uric acid an inexpensive widely available biomarker improves both the early diagnosis and risk stratification of patients with suspected AMI. © 2012 Stichting European Society for Clinical Investigation Journal Foundation.

Background Two preconditioning stimuli should induce a more consistent overall cell protection. We hypothesized that remote ischemic preconditioning (RIPC, second preconditioning stimulus) applied during isoflurane inhalation (first preconditioning stimulus) would provide more protection to the myocardium of patients undergoing on-pump coronary artery bypass grafting. Methods In this placebo-controlled randomized controlled study, patients in the RIPC group received four 5-min cycles of 300 mmHg cuff inflation/deflation of the leg before aortic cross-clamping. Anesthesia consisted of opioids and propofol for induction and isoflurane for maintenance. The primary outcome was high-sensitivity cardiac troponin T release. Secondary endpoints were plasma levels of N-terminal pro-brain natriuretic peptide, high-sensitivity C-reactive protein, S100 protein, and short- and long-term clinical outcomes. Gene expression profiles were obtained from atrial tissue using microarrays. Results RIPC (n = 27) did not reduce high-sensitivity cardiac troponin T release when compared with placebo (n = 28). Likewise, N-terminal pro-brain natriuretic peptide, a marker of myocardial dysfunction; high-sensitivity C-reactive protein, a marker of perioperative inflammatory response; and S100, a marker of cerebral injury, were not different between the groups. The incidence for the perioperative composite endpoint combining new arrhythmias and myocardial infarctions was higher in the RIPC group than the placebo group (14/27 vs. 6/28, P = 0.036). However, there was no difference in the 6-month cardiovascular outcome. N-terminal pro-brain natriuretic peptide release correlated with isoflurane-induced transcriptional changes in fatty-acid metabolism (P = 0.001) and DNA-damage signaling (P < 0.001), but not with RIPC-induced changes in gene expression. Conclusions RIPC applied during isoflurane inhalation provides no benefit to the myocardium of patients undergoing on-pump coronary artery bypass grafting.

Aims We sought to examine the diagnostic and prognostic utility of sensitive cardiac troponin (cTn) assays in patients with pre-existing coronary artery disease (CAD). Methods and results We conducted a multicentre study to examine the diagnostic accuracy of one high-sensitive and two sensitive cTn assays in 1098 consecutive patients presenting with symptoms suggestive of acute myocardial infarction (AMI), of whom 401 (37%) had pre-existing CAD. Measurements of Roche high-sensitive cTnT (hs-cTnT), Siemens cTnI-Ultra, Abbott-Architect cTnI and the standard assay (Roche cTnT) were performed in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists. Acute myocardial infarction was the final diagnosis in 19% of CAD patients. Among patients with diagnoses other than AMI, baseline cTn levels were elevated above the 99th percentile with Roche hs-cTnT in 40%, with Siemens TnI-Ultra in 15%, and Abbott-Architect cTnI in 13% of them. In patients with pre-existing CAD, the diagnostic accuracy at presentation, quantified by the area under the receiver operator characteristic curve (AUC), was significantly greater for the sensitive cTn assays compared with the standard assay (AUC for Roche hs-cTnT, 0.92; Siemens cTnI-Ultra, 0.94; and Abbott-Architect cTnI, 0.93 vs. AUC for the standard assay, 0.87; P < 0.01 for all comparisons). Elevated levels of cTn measured with the sensitive assays predicted mortality irrespective of pre-existing CAD, age, sex, and cardiovascular risk factors. Conclusion Sensitive cTn assays have high-diagnostic accuracy also in CAD patients. Mild elevations are common in non-AMI patients and test-specific optimal cut-off levels tend to be higher in CAD patients than in patients without history of CAD. Sensitive cTn assays also retain prognostic value. (ClinicalTrials.gov number, [NCT00470587][1]). [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00470587&atom=%2Fehj%2Fearly%2F2011%2F10%2F31%2Feurheartj.ehr376.atom

Background: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI. Methods: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up. Results: Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as “rule-out,” 76 patients (17%) as “rule-in,” and 101 patients (23%) as in the “observational zone” within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P.001) in patients classified as ruleout, observational zone, and rule-in, respectively. Conclusions: Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.

Background— We hypothesized that high-sensitivity cardiac troponin (hs-cTn) and its early change are useful in distinguishing acute myocardial infarction (AMI) from acute cardiac noncoronary artery disease. Methods and Results— In a prospective, international multicenter study, hs-cTn was measured with 3 assays (hs-cTnT, Roche Diagnostics; hs-cTnI, Beckman-Coulter; hs-cTnI Siemens) in a blinded fashion at presentation and serially thereafter in 887 unselected patients with acute chest pain. Accuracy of the combination of presentation values with serial changes was compared against a final diagnosis adjudicated by 2 independent cardiologists. AMI was the adjudicated final diagnosis in 127 patients (15%); cardiac noncoronary artery disease, in 124 (14%). Patients with AMI had higher median presentation values of hs-cTnT (0.113 μg/L [interquartile range, 0.049–0.246 μg/L] versus 0.012 μg/L [interquartile range, 0.006–0.034 μg/L]; P P Conclusion— The combined use of hs-cTn at presentation and its early absolute change excellently discriminates between patients with AMI and those with cardiac noncoronary artery disease. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00470587.

BACKGROUND Myocardial ischemia is a strong trigger of N terminal pro B type natriuretic peptide (NT proBNP) release. As ischemia precedes necrosis in acute myocardial infarction we hypothesized that NT proBNP might be useful in the early diagnosis and risk stratification of patients with suspected acute myocardial infarction. METHODS In a prospective multicenter study NT proBNP was measured at presentation in 658 consecutive patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality. RESULTS Acute myocardial infarction was the adjudicated final diagnosis in 117 patients (18). NT proBNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other final diagnoses (median 886 pg/mL vs 135 pg/mL P

Objectives. The concentration of atrial natriuretic peptide (ANP) in the circulation is approximately 10- to 50- fold higher than B-type natriuretic peptide (BNP). We sought to compare the accuracy of midregional pro-atrial natriuretic peptide (MRproANP) measured with a novel sandwich immunoassay with N-terminal pro-B-type natriuretic peptide (NTproBNP) in the diagnosis of heart failure. Design. The diagnosis of heart failure was adjudicated by two independent cardiologists using all available clinical data (including BNP levels) in 287 consecutive patients presenting with dyspnoea to the emergency department (ED). MRproANP and NTproBNP levels were determined at presentation in a blinded fashion. Results. Heart failure was the adjudicated final diagnosis in 154 patients (54%). Median MRproANP was significantly higher in patients with heart failure as compared to patients with other causes of dyspnoea (400 vs. 92 pmol L -1 , P < 0.001). The diagnostic accuracy of MRproANP was very high with an area under the receiver operating characteristic curve of 0.92 and was comparable with that of NTproBNP (0.92, P = 0.791). Moreover, MRproANP provided incremental diagnostic information to BNP and NTproBNP in patients presenting with BNP levels in the grey zone between 100 and 500 pg mL -1 . Conclusion. Midregional pro-atrial natriuretic peptide is as accurate in the diagnosis of heart failure as NTproBNP. MRproANP seems to provide incremental information on top of BNP or NT-proBNP in some subgroups and should be further investigated in other studies.

Background There is accumulating evidence that transient exercise-induced ischemia triggers the release of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP). The aim of this study was to either confirm or refute a previous investigation suggesting that myocardial ischemia can reliably be detected by exercise-induced changes in BNP or NT-proBNP levels in selected patients. Methods A total of 139 consecutive patients with normal left ventricular function and normal resting BNP and NT-proBNP levels referred for rest/stress myocardial perfusion single-photon emission computed tomography (SPECT) were analyzed. Levels of BNP and NT-proBNP were determined before and immediately after symptom-limited bicycle ergometry. Results Inducible myocardial ischemia on perfusion images was detected in 46 patients (33%). Median exercise-induced increases in BNP (ΔBNP) and NT-proBNP (ΔNT-proBNP) were similar in patients with and without inducible ischemia (ΔBNP 12.7 pg/ml vs. 9.4 pg/ml, p =0.109; ΔNT-proBNP 7 pg/ml vs. 6 pg/ml, p =0.309). The area under the receiver operating characteristic curve for the ability to detect myocardial ischemia was 0.583 (95% CI, 0.479–0.688) for ΔBNP, and 0.553 (95% CI, 0.450–0.656) for ΔNT-proBNP. Conclusions Exercise-induced changes in BNP and NT-proBNP do not reliably detect myocardial ischemia in selected patients.

The CNS immune response often leads to characteristic interrelated biochemical changes in cerebrospinal fluid. Multiple analytes, i.e. cell count, cell differential, evaluation of barrier function and intrathecal IgG, IgA and IgM synthesis should be included in basic diagnostic workup. We describe the scientific background, laboratory investigations and characteristic patterns found with basic CSF analysis, based on the recommendations of the German cerebrospinal fluid society. The concept is substantiated by retrospectively analyzing data of 4026 paired CSF/serum samples. 53% of our samples presented with at least one or several combined abnormal findings. An intrathecal IgG, IgA or IgM immunoglobulin response (37%, n=1481) and a blood-CSF barrier dysfunction (37%; n=1473) were most frequent; followed by an elevated leukocyte cell count (25%; n=992). The immunoglobulin response showed an intrathecal production of IgG in 49% (n=731/1481), which was only detectable in isoelectric focusing in 27% (n=200/731). Intrathecal IgM (n=389) and IgA (n=361) synthesis presented with nearly equal frequency of 25% in samples with intrathecal immunoglobulin response. The immunoglobulin pattern showed a solitary one class reaction of IgG, IgA or IgM in 67%, a combined two class reaction of IgG/IgA, IgG/IgM or IgA/IgM synthesis in 16% and a combined three-class reaction of IgG, IgA and IgM in 17%. This approach generates valuable but numerous complex and interrelated biochemical data. We therefore developed a knowledge-based system combined with visual oriented laboratory output to transfer the information more effectively. This often uncovers typical patterns specific for distinct neurological diseases, is well accepted by our medical community documented by a 37% increase in external ordering.

UNLABELLED HISTORY AND SYMPTOMS: For 11 weeks a 38-year-old woman had suffered from a respiratory infection with peribronchitis, nocturnal coughing fits and earache. INVESTIGATIONS, TREATMENT AND COURSE The Chlamydia-CFR titre was raised. Subsequent throat swabs of her husband and two daughters grew Chlamydia pneumoniae (C.p.), but not in her case; 5 days earlier she had been started on roxithromycin. 3 weeks before the patient fell ill her two daughters had a flu-like illness with cough and subfebrile temperature and her husband also had flu-like symptoms, which regressed after few days. Antibiotic treatment with roxithromycin improved the symptoms in the mother and older daughter, but the younger daughter was not given treatment because she had no symptoms at the time the microorganism had been isolated. She developed joint symptoms, like those of reactive arthritis, 12 weeks after the mother's illness had begun, and conjunctivitis 5 weeks later. CONCLUSIONS It is likely that the daughters had the C.p. infection first and then infected their parents. While the father's and older daughter's illness quickly regressed, the mother became quite ill. Her serology was positive for a primary infection in adulthood, but in the daughters the serology was negative and, despite demonstration of the organism, the diagnosis of acute C.p. infection could not be made.

OBJECTIVE: We explored whether hemodynamic cardiac stress leads to a differential release of cardiomyocyte injury biomarkers, used in the diagnosis of acute myocardial infarction (AMI). METHODS: In an observational international multicenter study, we enrolled 831 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists. Hemodynamic cardiac stress was quantified by levels of B-type natriuretic peptide (BNP). Spearman's rho correlation was used to analyze the correlations between BNP and high-sensitivity cardiac troponin T (hs-cTnT), Siemens cTnI-Ultra (cTnI-ultra), CK-MB and Myoglobin. Patients were categorized according to the extent of hemodynamic cardiac stress as quantified by BNP tertiles. RESULTS: Among all patients, the positive pair-wise correlation with BNP was strongest with hs-cTnT and cTnI-ultra (r=0.58 and 0.50, respectively), moderate for Myoglobin (r=0.43), and weakest with CK-MB (r=0.25; p

Iron is an essential metabolite for pathogenic bacteria, and the specificity exhibited by bacteria for host-iron chelates may be correlated with host and tissue tropism. The effect of iron restriction on Chlamydia pneumoniae and C. trachomatis was studied by use of the iron-chelating compound deferoxamine. Growth of C. pneumoniae was inhibited much more than that of C. trachomatis and the effect of iron restriction largely depended on the cell line used for propagation. This might reflect differences in tissue tropism of the two chlamydial species. As iron levels are usually higher in men than in women, this might also be connected with the higher prevalence rate of C. pneumoniae antibodies in males, observed in all populations studied so far.

A recently described 54-kDa protein has been detected in six type strains and three patient isolates of Chlamydia pneumoniae by immunoblotting with sera from patients positive for antibodies to C. pneumoniae by the microimmunofluorescence test. This protein was not found in either C. trachomatis E or C. psittaci Z 432 as an antigen, confirming its species specificity. The 54-kDa protein was isolated by continuous-elution electrophoresis and immunoglobulin G monoclonal antibodies (MAbs) against the isolated antigen were produced. MAb 8B11E6 reacted only with the 54-kDa band of C. pneumoniae and not with C. trachomatis E or C. psittaci in a Western immunoblot assay. This antibody was purified and tested for neutralizing activity together with three additional anti-p54-active MAbs (8B11E6, 8B11B4, and 10F1C1). In Buffalo green monkey cells, all of the MAbs significantly reduced the infectivity of C. pneumoniae elementary bodies, whereas no neutralizing activity could be observed with C. trachomatis E or C. psittaci Z 432. These results not only confirm the species specificity of the 54-kDa protein but also indicate that this protein might play an important role in the pathogenesis of C. pneumoniae infection. Furthermore, the results suggest a possible protective role of anti-p54 antibodies in an adaptive immune response.

Genital chlamydial infections persist for years in both women and men. Because of low numbers of organisms found in the urogenital tract direct detection of Chlamydia trachomatis may be difficult. In these cases serology serves as a useful diagnostic supplement in clinically suspected infection or tubal factor sterility. A total of 178 sterility patients (63 with pelviscopically proven occluded, 115 with open fallopian tubes), 103 women with positive cervical swabs, 100 obstetric patients (6% with positive cervical swabs), and 100 blood donors were serologically tested. The following tests were used: 1. microimmunofluorescence test (MIF, Graystone), 2. a commercial test using lipopolysaccharide (LPS) extracted elementary bodies as antigen, 3. a commercial whole inclusion test, 4. a commercial recombinant chlamydial LPS test. The positive predictive values of these tests were 71%, 65%, 66%, 52% for tubal occlusion and 40%, 40%, 21%,13% for a positive cervical swab (obstetric patients), respectively. Principally, only the Chlamydia trachomatis species-specific tests (MIF test and LPS extracted elementary body test) were suited for gynaecological chlamydial diagnostics. Due to its cross-reactivity with Chlamydia pneumoniae the whole inclusion test should be restricted to high prevalence groups such as sterility patients. The genus-specific LPS test proved to be of no help for the gynaecologist. No serological test allowed any differentiation between past and present infection with Chlamydia trachomatis.

The impact of different forms of cardiac stress testing (exercise versus pharmacological stress testing) on cardiac wall stress and myocardial ischemia is incompletely understood.In a prospective study, 331 consecutive patients with suspected myocardial ischemia referred for nuclear perfusion imaging were enrolled: 266 underwent exercise (bicycle) stress testing and 65 adenosine stress testing. Levels of B-type natriuretic peptide (BNP) measured before and 1 min after stress testing, ischemic ECG changes, and typical angina symptoms were used to compare the 2 testing modalities.Cardiac wall stress as quantified by changes in BNP levels significantly increased in the exercise stress group, but not in the adenosine group (increase in BNP levels 22 pg/ml (IQR 6-46) versus -3 pg/ml (IQR -3 to 28); p0.001). In the bicycle exercise stress group, patients with reversible defects on nuclear perfusion imaging more often had angina symptoms (25% vs. 9%, p=0.0001) and ischemic ECG changes (33% vs. 12%, p=0.0001) during the stress test, and a greater increase in BNP levels (28 (IQR 11-58) versus 16 (IQR 3-34) pg/ml, p=0.001) compared to those without reversible defects. Those differences between patients with and without reversible defects were not observed with the adenosine protocol (p-values all0.05).Exercise stress testing but not adenosine stress results in an increase of cardiac wall stress, angina symptoms and ECG changes. The absence of these surrogates of myocardial ischemia suggests that adenosine stress does not induce acute myocardial ischemia, but rather displays relative perfusion differences.

BACKGROUND Current guidelines require a change (rise and/or fall) in levels of cardiac troponin (cTn) for the diagnosis of acute myocardial infarction (AMI). It is unknown whether absolute or relative changes provide higher accuracy when using high sensitivity cTnI assays. METHODS In a prospective international multicentre study we assessed the diagnostic accuracy of early absolute and relative changes in cTnI measured with two novel pre commercial high sensitivity assays (Siemens and Beckman Coulter) in 943 unselected patients presenting to the ED with suspected AMI. The final diagnosis of AMI was adjudicated using all available data including serial hs cTnT levels by two independent cardiologists. RESULTS The diagnostic accuracy of absolute changes in the diagnosis of AMI as quantified by the area under the receiver operating characteristics curve (AUC) was very high (e.g. at 2h Siemens high sensitivity cTnI AUC 0.93 95Cl 0.90 0.96; Beckman Coulter high sensitivity cTnI AUC 0.93 95Cl 0.90 0.96) and superior to relative changes at all time points (p

We thank Lippi et al1 for their interest in our work.2 They mention the fact that turnaround time may be >1 hour in many institutions. It is important to highlight that this observation does not interfere with our data or our conclusions. Our study refers to the time interval between the blood draw at presentation and the second blood draw. We fully agree with Lippi et al that, because of the turnaround time of ≈60 minutes, the results of the sample drawn at presentation will only become available for clinicians after 1 hour and the results of the 1-hour blood draw will only become available after 2 hours. We also fully agree with Lippi et al that …

A total of 276 cervical swabs (241 from first visits and 35 from follow-up visits) from 241 women were tested for Chlamydia trachomatis by polymerase chain reaction (PCR) and enzyme immunoassay (EIA). Sixty-one smears (53 from first visits and 8 from follow-up visits) from 53 women were stained by direct fluorescent antibody (DFA). Twenty-one (8.7%) women had positive swabs in at least two different tests. All follow-up swabs (collected between 3 days and 3 weeks after the first clinical visit) were positive in at least one test when the woman had been positive at the first visit and no antibiotic treatment had been initiated. Including swabs from follow-up visits and DFA results, the respective sensitivities and specificities of the assays were as follows: PCR, 75.9% and 100%; EIA, 69% and 98.4%. The seven swabs that were false negative by PCR (tested initially after thawing from -20 degrees C) were mailed nonrefrigerated to the assay manufacturer, where they tested true positive. These data point to labile inhibitors of the PCR, predominantly cervical mucus.

Background: Absolute changes in high sensitivity cardiac troponin T (hs cTnT) seem to have higher diagnostic accuracy in the early diagnosis of acute myocardial infarction compared with relative changes. It is unknown whether the same applies to high sensitivity cardiac troponin I (hs cTnI) assays and whether the combination of absolute and relative change might further increase accuracy. Methods: In a prospective international multicenter study high sensitivity cardiac troponin (hs cTn) was measured with 3 novel assays (hs cTnT Roche Diagnostics Corp Indianapolis Ind; hs cTnI Beckman Coulter Inc Brea Calif; hs cTnI Siemens Munich Germany) in a blinded fashion at presentation and after 1 and 2 hours in a blinded fashion in 830 unselected patients with suspected acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists. Results: The area under the receiver operating characteristic curve for diagnosing acute myocardial infarction was significantly higher for 1 and 2 hour absolute versus relative hs cTn changes for all 3 assays (P

A total of 446 sera from 245 patients with primary or secondary infertility, all of whom were examined laparoscopically, 117 patients with Chlamydia trachomatis-positive cervical swabs, and 84 control persons (50 obstetric patients and 34 female blood donors) were tested for antibodies to Chlamydia trachomatis and to Chlamydia pneumoniae with the microimmunofluorescence (MIF) test. MIF test antibody rates were highest in patients with complete tubal occlusion (73%) and in patients with proven Chlamydia trachomatis infection (74%), whereas only 9 to 10% of the control group showed Chlamydia trachomatis antibodies. Reaction to the 60 kDa antigen of Chlamydia trachomatis, a heat-shock protein (hsp) analogue, has been suggested as a possible marker for the development of chronic sequelae after Chlamydia trachomatis infection. Immunoblot analysis of 222 sera (169 infertility patients, 20 antigen-positive patients, and 33 mothers) showed a significantly higher anti-hsp antibody rate in patients with complete tubal occlusion than in infertility patients with normal fallopian tubes (76% vs. 19%, p0.001). The presence of antibodies not only to Chlamydia trachomatis but also to Chlamydia pneumoniae in the MIF test was associated with a significantly higher rate of anti-hsp antibodies and with complete tubal occlusion. This association did not appear to be due to cross-reactivity between Chlamydia pneumoniae and Chlamydia trachomatis antibodies in the MIF test.

BACKGROUND High-sensitivity cardiac troponin assays have better analytical precision and sensitivity than earlier-generation assays when measuring cardiac troponin at low concentrations. We evaluated whether use of a high-sensitivity assay could further improve risk stratification compared with a standard cardiac troponin assay. METHODS We enrolled consecutive patients presenting with acute chest pain, 30% of whom were diagnosed with acute coronary syndrome. Blood samples were drawn at the time of presentation. We measured cardiac troponin T with a standard fourth-generation assay (cTnT) and a high-sensitivity assay (hs-cTnT) (both Roche Diagnostics) and followed the patients for 24 months. RESULTS Of the 1159 patients, 76 died and 42 developed an acute myocardial infarction (AMI). Prognostic accuracy of hs-cTnT for death was significantly higher [area under ROC curve (AUC) 0.79, 95% CI 0.74–0.84] than that of cTnT (AUC 0.69, 95% CI 0.62–0.76; P < 0.001). After adjustment for Thrombolysis in Myocardial Infarction (TIMI) risk score (that included the cTnT assay result), hs-cTnT above the 99th percentile (0.014 μg/L) was associated with a hazard ratio for death of 2.60 (95% CI 1.42–4.74). Addition of hs-cTnT to the risk score improved the reclassification of patients (net reclassification improvement 0.91; 95% CI 0.67–1.14; P < 0.001). Subgroup analyses showed that this effect resulted from the better classification of patients without AMI at time of testing. hs-cTnT outperformed cTnT in the prediction of AMI during follow-up (P=0.02), but was not independently predictive for this endpoint. CONCLUSIONS Concentrations of hs-cTnT >0.014 μg/L improve the prediction of death but not subsequent AMI in unselected patients presenting with acute chest pain.

Aims Angiogenic factors play an important role in the development of atherosclerosis and show pronounced changes during acute myocardial infarction (AMI). We analysed the impact of placental growth factor (PlGF) and its endogen opponent, soluble fms-like tyrosine kinase-1 (sFlt-1), on clinical outcome and the early diagnosis of AMI. Methods and results This multicentre study enrolled patients presenting with symptoms suggestive of AMI. The final diagnosis was adjudicated by two independent physicians. Levels of sFlt-1 and PlGF were compared with results of a standard troponin T and a novel high-sensitive troponin (hsTnT) assay. Of the 763 patients enrolled, 132 were diagnosed with AMI. Multivariable Cox regression analysis demonstrated sFlt-1 >84 ng/L [hazard ratios (HR) 2.6, 95% confidence intervals (CI) 1.2-5.4, P=0.01] and PlGF >20 ng/L (HR 3.6, 95% CI 1.3-10.4, P=0.02) as predictors for mortality during 1-year follow-up, independent from information provided by troponin T and N-terminal pro-B-type natriuretic peptide (NT-proBNP). However, only sFlt-1 persisted as independent predictor for mortality when analysed together with hsTnT and NT-proBNP, and after adjusting for significant clinical parameters. For the diagnosis of AMI, the combination of troponin T and sFlt-1 improved the performance of troponin T alone and led to a negative predictive value of 98.3% already at time of presentation. However, sFlt-1 and PlGF added only limited diagnostic information when used together with hsTnT. Conclusion Only sFlt-1 but not PlGF provides overall independent prognostic information in patients presenting with symptoms suggestive of AMI. After the introduction of hsTnT in clinical routine, sFlt-1 and PlGF can only add limited diagnostic information for the detection or exclusion of AMI. Clinical Trial Registration Information: ClinicalTrials.gov, NCT00470587

BACKGROUND Myocardial ischemia is a strong trigger of B type natriuretic peptide (BNP) release. As ischemia precedes necrosis in acute myocardial infarction we hypothesized that BNP might be useful in the early diagnosis and risk stratification of patients with acute chest pain. METHODS In a prospective international multicenter study BNP was measured in 1075 unselected patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality. RESULTS Acute myocardial infarction was the adjudicated final diagnosis in 168 patients (16). BNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other diagnoses (median 224 pg/mL vs. 56 pg/mL P

ObjectivesThe purpose of this study was to examine the incremental value of copeptin for rapid rule out of acute myocardial infarction (AMI).BackgroundThe rapid and reliable exclusion of AMI is a major unmet clinical need. Copeptin, the C-terminal part of the vasopressin prohormone, as a marker of acute endogenous stress may be useful in this setting.MethodsIn 487 consecutive patients presenting to the emergency department with symptoms suggestive of AMI, we measured levels of copeptin at presentation, using a novel sandwich immunoluminometric assay in a blinded fashion. The final diagnosis was adjudicated by 2 independent cardiologists using all available data.ResultsThe adjudicated final diagnosis was AMI in 81 patients (17%). Copeptin levels were significantly higher in AMI patients compared with those in patients having other diagnoses (median 20.8 pmol/l vs. 6.0 pmol/l, p < 0.001). The combination of troponin T and copeptin at initial presentation resulted in an area under the receiver-operating characteristic curve of 0.97 (95% confidence interval: 0.95 to 0.98), which was significantly higher than the 0.86 (95% confidence interval: 0.80 to 0.92) for troponin T alone (p < 0.001). A copeptin level

The susceptibilities of six Chlamydia pneumoniae type strains and of six German patient isolates to erythromycin, azithromycin, roxithromycin, clarithromycin, doxycycline, ofloxacin, and rifampin were investigated. MICs and minimal chlamydicidal concentrations were all within the ranges reported previously. Combinations of azithromycin with either ofloxacin, doxycycline, or rifampin, as well as combinations of three antibiotics (rifampin, azithromycin, and ofloxacin or doxycycline), showed synergistic activity against C. pneumoniae .

Chronic kidney disease is often not associated with significant symptoms or abnormalities in common laboratory test results. Diagnosis is supposedly facilitated by calculating the glomerular filtration rate (GFR) from serum creatinine. A reference range GFR, however, does not exclude renal disease, because renal disease causes the subsequent decrease of renal function. Thorough analysis of proteinuria, however, requires a profound knowledge of the renal handling of the different marker proteins of glomerular and tubular origin. This paper summarizes the scientific basis, explains the diagnostic rationale and proves the concept by analyzing 5669 samples, where GFR and proteinuria work-up were available. 63% (1446 of 2287) of the samples with a GFR above 60 showed either glomerular (37.8%, n=865) or tubular proteinuria (25.4%, n= 581). The quantity of proteinuria increased severely with decreasing kidney function. The rate of glomerular proteinuria remained nearly constant in the different GFR groups, while primarily tubular proteinuria increased from 23% to 63%. A proteinuria pattern indicating a good response to therapy was frequently combined with a high GFR (selective glomerular proteinuria/ incomplete tubular proteinuria), while the severe forms of unselective or complete tubular proteinuria associated with a severe GFR decrease. Regression analysis showed a better inverse correlation of GFR with tubular (r=-0.643) than glomerular markers (r=-0.360; combined r=-0.646). We believe that this complex interrelated laboratory information must be delivered most effectively, i.e. with the use of a knowledge based system in combination with improved, visual oriented laboratory output.

Zusammenfassung. Ein neuer Sandwich-Antigen-ELISA zum Nachweis von Aspergillus-Galactomannan im Blutplasma wurde mit dem Latex-Agglutinations-Test anhand von sechs Patienten mit histologisch gesicherter invasiver Aspergillose verglichen. Der Antigen-ELISA zeigte sich dem Latex-Test in zweierlei Hinsicht uberlegen: Alle sechs Patienten wurden vom Antigen-ELISA richtig als positiv erkannt, wahrend dies beim Latex-Test nur in 5/6 der Fall war. Auserdem lieferte der Antigen-ELISA im Mittel 19 Tage fruher als der Latex-Test ein positives Testergebnis. Summary. A new sandwich antigen enzyme-linked immunosorbent assay (ELISA) for the detection of Aspergillus galactomannan in blood plasma was compared with the latex-agglutination test by investigation of six patients with histologically proven invasive aspergillosis. The ELISA gave positive results in all six patients while the latex test recognized 5/6 as positive. On an average the antigen ELISA gave positive results 19 days earlier than the latex test.

The incidence of community-acquired pneumonia (CAP) due to Chlamydia pneumoniae was determined in a prospective study of 546 adult patients with CAP included in the German CAP Competence Network (CAPNETZ) project. Three different PCR protocols for detection of C. pneumoniae in respiratory specimens were compared by a multicenter, inter-laboratory comparison involving three laboratories. A case was defined as a patient with a respiratory sample positive by PCR in at least two laboratories. CAP was caused by C. pneumoniae in 5/546 cases (0.9%). Antibody testing by microimmunofluorescence was done in 376 of 546 patients. All patients were negative for IgM antibodies. In the five PCR-positive patients, neither specific IgG nor IgA antibodies were found. Patients with CAP caused by C. pneumoniae had a lower median age (36 years) than the general study population (62 years). C. pneumoniae is currently a rare cause of CAP in adult patients in Germany. Analysis of a single serum sample is not useful for diagnosis of acute C. pneumoniae infection in CAP.

In the study presented here, peripheral blood specimens obtained from patients with atherosclerosis were examined for the presence of Chlamydia pneumoniae to determine whether these specimens can be used for routine testing. Chlamydia pneumoniae DNA was detected in 7 of 56 patients with carotid stenosis and in three of four patients with other atherosclerotic diseases, but it was not detected in any of 50 healthy controls or in any of 59 age- and gender-matched patients suffering from other nonatherosclerotic diseases. IgG antibodies indicative of an active Chlamydia pneumoniae infection were detected by microimmunofluorescence in two of nine PCR-positive patients but in none of 41 PCR-negative patients. Four of nine serum samples obtained from PCR-positive patients contained IgA antibodies compared to 5 of 41 samples obtained from PCR-negative patients.

Microimmunofluorescence (MIF), a Chlamydia trachomatis species-specific enzyme immunoassay incorporating lipopolysaccharide-extracted Chlamydia trachomatis L2 elementary bodies, two different synthetic peptide-based species-specific tests, and a recombinant lipopolysaccharide genus-specific test were performed on multiple follow-up sera (n = 104 total) from 16 women with Chlamydia trachomatis-positive cervical swabs. These women included five with IgG seroconversions, five with Chlamydia trachomatis reinfections after initial therapy, and six with serologic follow-up of more than 6 years after antibiotic therapy. Of all the tests employed in this study, MIF IgG reverted earliest to negative titers, while MIF IgA was the least sensitive. The lipopolysaccharide-extracted elementary body enzyme immunoassay exhibited the closest correlation with the MIF test. The highest test sensitivity was observed in one of the synthetic peptide-based tests, which detected earliest seroconversions and longest IgG persistence. The other synthetic peptide-based test gave false-negative results in 2 of 16 women and did not detect seroconversion earlier than the MIF test. Seroconversion and persistence of genus-specific IgG--cross-reactivity with Chlamydia pneumoniae--against lipopolysaccharide were similar to species-specific IgG. A significant serologic response to reinfection was observed only in women with signs of pelvic inflammatory disease. Species-specific tests of high sensitivity and reproducibility are best suited for gynecological diagnostic purposes.

Versteht man unter „Routinelabor“ das Anforderungsprofil, das unabhangig von Anamnese und klinischem Befund bei jedem Patienten mit zunachst unbekannter Diagnose oder unbekannter Komplikation eines Patienten mit bekannter Diagnose sinnvoll und notwendig ist, so sind vereinfacht zwei Situationen zu unterscheiden

We report a case of a severe Fusarium solani keratitis in a 82-year-old patient with a history of surgical trauma. Antimycotic therapy and keratoplasty led to markedly improved vision. Identification of the fungus was complicated by the fact that the isolate did not produce the typical macroconidia. The second case was a fatal disseminated Fusarium verticillioides infection in a 69-year-old patient during neutropenia after chemotherapy of acute myelogenous leukemia. The patient developed pneumonia, fever, skin lesions, myalgia, and fungaemia. The clinical signs, diagnosis and therapy of localized and disseminated Fusarium infections are outlined and discussed in view of the literature.

The immunoblot patterns of 248 sera, all examined previously by the microimmunofluorescence test (MIF) for species-specific Chlamydia antibodies, were analyzed. Predominant specific antibody activity was directed to the 54 kDa protein of Chlamydia pneumoniae, which was recognized by 93% of sera positive for Chlamydia pneumoniae by MIF but by only 2% of sera positive for Chlamydia trachomatis and negative for Chlamydia pneumoniae and by 3% of sera negative for both Chlamydia pneumoniae and Chlamydia trachomatis. This antigen appears to be specific for Chlamydia pneumoniae. Other Chlamydia pneumoniae-specific protein antigens were recognized far less frequently. Absorption analysis indicated that the 54 kDa protein is located on the surface of the Chlamydia pneumoniae elementary bodies.

In cases of reactive arthritis, a suspected Chlamydia trachomatis infection is often detected by serological methods. However, mostly tests with genus-specific antigens are used, neglecting the fact that antibodies against Chlamydia pneumoniae are highly prevalent in the adult population. Therefore we tested sera of 129 patients with various rheumatological disorders and of 18 healthy persons in parallel with a genus-specific test (IPAZYME) and with the species-specific microimmunofluorescence test for C. trachomatis and C. pneumoniae antibodies. The data showed that 55% of the 64 IPA-positive results were caused by antibodies (IgG) against Chlamydia pneumoniae, only 6% by anti-Chlamydia trachomatis IgG and 20% by both specificities. For IgA antibodies, the percentages were 44%, 12.5% and 12.5% respectively. In 12 IPA-positive cases, the MIF showed no reaction. 58% of all 147 sera tested with MIF had IgG antibodies against C. pneumoniae, 5% had anti-C. trachomatis IgG and 8% IgG against both species. The percentages for IgA were 29%, 2% and 2%, respectively. IgM positivity in MIF disappeared after absorption with rheumatoid factor absorbent. No significant differences were found between the various groups of patients. The data suggest that due to the high prevalence of anti-C. pneumoniae antibody, genus-species tests cannot be used as screening tests for the serological diagnosis of C. trachomatis infections.

Summary Prevalence of antibodies to Chlamydia pneumoniae TWAR in Germany has not been previously evaluated. Therefore a healthy adult population of 353 German medical students (mean age 24 years) was examined with a species-specific microimmunofluorescence test for IgG, IgM and IgA antibodies to C. pneumoniae and in parallel to Chlamydia trachomatis . Altogether, 229 persons had IgG antibodies to C. pneumoniae (64·9 %), 136 had IgA antibodies (38·5 %), while the serum of only one contained specific IgM. Prevalence rates were higher in males (69·4 %) than in females (57·3 %). The total prevalence for antibodies to C. trachomatis was 5·9%. The results indicate that C. pneumoniae infections are highly endemic in Germany, and that primary infection probably takes place in children or young adults. Prevalence of antibodies to C. pneumoniae in this group of healthy young adults was about 10-fold higher than that to C. trachomatis . This finding needs to be taken into account when genus-specific tests are used for studying Chlamydial antibodies.

A patient with short bowel syndrome as a consequence of multiple intestinal resections for Crohn's disease, had a port system implanted to improve her nutritional status. One year later she presented with fever, weakness and nighttime sweating. Metschnikowia pulcherrima Pitt et Miller was grown in blood cultures from the port system. After antifungal chemotherapy using fluconazole and removal of the implant, the patient's condition improved markedly and her fever and sweating disappeared. We conclude that Metschnikowia pulcherrima can turn into a human pathogen in patients with indwelling catheters for parenteral nutrition. Chemotherapy with fluconazole and, whenever possible, removal of the implant, appear to be adequate treatment.

In a prospective study Cryptosporidium spp. were detected in nine immunocompetent patients (0.6 %). The frequency was remarkably higher in children in the 0 to 14 year age group (1.6 %), surpassed only by Salmonella spp. and Campylobacter spp. The predominant clinical features were watery diarrhea, abdominal pain, and vomiting. Comparison of the epidemiological data of the patients with those of a control group showed that contact persons with enteritis and drinking of unpasteurized milk were significantly associated with cryptosporidiosis.