Chest pain in the emergency room. Importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.

Study of Coronary Flow Reserve with Intravenous Use of Microbubbles (Contrast Echocardiography) and Adenosine: Protocol for Clinical Application in Patients Suspected of Having Coronary Heart Disease

OBJECTIVE: To test the feasibility, safety and accuracy of the adenosine protocol in the study of myocardial perfusion with microbubbles contrast echocardiography. METHODS: 81 pts (64 male, 60+11 years) were submitted to contrast echocardiography with PESDA (sonicated solution of albumin 20%-1ml, dextrose 5%-12ml and deca-fluorobutane gas-8ml) to study the myocardial perfusion at rest and after bolus injection of adenosine (6 to 18mg) and to coronary angiography within 1 month each other. For each patient 3 left ventricle perfusion beds were considered (total of 243 territories). 208 territories were analyzed and 35 territories were excluded. PESDA was continuously infused (1-2ml/min), titrated for best myocardial contrast. Triggered (1:1) second harmonic imaging was used. RESULTS: Coronary angiography showed 70 flow limiting (> 75%) lesions and 138 no flow limiting lesions. At rest an obvious myocardium contrast enhancement was seen in at least 1 segment of a territory in all patients. After adenosine injection an unquestionable further increase in myocardial contrast was observed in 136 territories (99%) related to no flow limiting lesions, lasting < 10 s, and a myocardial perfusion defect was detected in 68 territories (97%) related to flow limiting lesions. It was observed only 4 false results. There were no serious complications. CONCLUSION: Myocardial perfusion study with PESDA and adenosine protocol is a practical, safe and accurate method to analyze the coronary flow reserve.

Association of Peripheral Arterial and Cardiovascular Diseases in Familial Hypercholesterolemia

Background: Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease characterized by an elevation in the serum levels of total cholesterol and of low-density lipoproteins (LDL- c). Known to be closely related to the atherosclerotic process, FH can determine the development of early obstructive lesions in different arterial beds. In this context, FH has also been proposed to be a risk factor for peripheral arterial disease (PAD). Objective: This observational cross-sectional study assessed the association of PAD with other manifestations of cardiovascular disease (CVD), such as coronary artery and cerebrovascular disease, in patients with heterozygous FH. Methods: The diagnosis of PAD was established by ankle-brachial index (ABI) values ≤ 0.90. This study assessed 202 patients (35% of men) with heterozygous FH (90.6% with LDL receptor mutations), mean age of 51 ± 14 years and total cholesterol levels of 342 ± 86 mg /dL. Results: The prevalences of PAD and previous CVD were 17% and 28.2 %, respectively. On multivariate analysis, an independent association between CVD and the diagnosis of PAD was observed (OR = 2.50; 95% CI: 1.004 - 6.230; p = 0.049). Conclusion: Systematic screening for PAD by use of ABI is feasible to assess patients with FH, and it might indicate an increased risk for CVD. However, further studies are required to determine the role of ABI as a tool to assess the cardiovascular risk of those patients.

Análise de poliembrionia em Citrus, máxime em toranjas

1 - This paper is a joined publication of the Dept. of Genetics, Escola Superior de Agricultura "Luiz de Queiroz", University of São Paulo, and Secção de Citricultura e Frutas Tropicais, Instituto Agronômico, de Campinas, and deal with the number of seed per fruit and the polyembryony in Citrus, with special reference to the pummelos (C. grandis). 2 - For C. pectinifera, hibrid limon x acid lime, C. histrix and Citrus sp. the mean of seeds per fruit is 5,8 - 17,3 - 30,2 -94,6; for 14 pummelos the average was 100 and the range of variation 11 to 185 seeds per fruit. For the four above mentioned Citrus the cotyledons were classified into 3 types: big (near 8 mm.), medium (near 6 mm) and small (near 4 mm) and for the pummelos there was only one size of cotyledons, about 10 mm (table 1). 3 - The polyembryony was determined by two processes: a) counting of the embryos in the mature seed; b) counting after germination in flats or seed-beds. The rasults obtained are in table 2; the process a gave larger results than process b.The following pummelos are monoembryonics: melancia, inerme, Kaune Paune, sunshine, vermelha, Singapura, periforme, Zamboa, doce, Indochina, Lau-Tau, Shantenyau and Siamesa. Sometime it was found a branching of the main stem that gave a impression of polyembryonic seeds. 4 - It was shown by the x2 test that the distribution of embryo numbers fits the Poisson's series (table 2) in both processes. 5 - It is discussed in table 2 the variability of polyembryony for the following cases: a) between plants, within years. The teste for the differences of mean of polyembryony between 3 plants of C. pectinifera is statistically significant in 1948 and 1949; b) between yields of the same plant, within year. The same case of C. pectinifera may be used for this purpose; c) between process, within year. It is shown in table 3, for C. pectinifera and the hibrid "limon x acid lime" that there is a statistically signicicant between both process above mentioned.

Experimentos com os nematieidas D. D, E.D.B., C.B.P. e Vapam no combate aos nematódeos que parasitam a batatinha em São Paulo

The writers report results on the application of four fumigants (D. D., E. D. B.-40, C. B. P. and Vapam) for control of root-knot and meadow nematodes attacking potato in beds filled with soil artificially inoculated. The data obtained were as follows: a) as reported by previous authors, potato is sensitive to C.B.P., the toxical effects of which disapearing only about 6 and half months after application. On the other hand, C.B.P. proved to have a significative residual nematicidal value, protecting the seeds from root-knot nematodes for a period of two years; b) D. D., E. D. B., and Vapam were effective for controling root-knot but with no residual value, having to be used prior to each planting; c) at the rates used, no nematicide was effective to control meadow nematodes; d) in the conditions of the experiments, all nematicides incited attacks bv Streptomyces scabies. Actually, in some cases scab did not affect any tuber from the check while the entire production from the treated beds was heavily desfigured. The writers assume that as the nematicides killed protozoa and too many bacteria-eating nematodes, they destroyed the biological equilibrium existing in the soil, thus allowing the S. scabies population to reach a high level.

Two new species of Caulleriella (Polychaeta, Cirratulidae) from Argentina

Caulleriella bremecae and C. galeanoi (Polychaeta: Cirratulidae) are newly described from Mar del Plata, Argentina (38ºS, 57ºW). Both species have small, red-pigmented nuchal organs (lateral "eyes") on the prostomium. Caulleriella bremecae sp. nov. is further characterized by a peristomium without annulations except for a narrow anterior dorsal fold, posterior part of peristomium extending posterodorsally over chaetiger 1, latter extending posterodorsally over chaetiger 2 and with slightly separated grooved palps arising middorsally; notochaetae of chaetigers 1-23 all smooth capillaries, thereafter with six bidentate sigmoid hooks and 3-4 capillaries, both types fewer on last 4-5 chaetigers; neurochaetae of chaetigers 1-2 comprised of 8 bidentate hooks and 1-2 capillaries, thereafter only bidentate hooks, decreasing in number posteriorly. The species is frequent and abundant throughout the year in the intertidal mussel beds situated 200-700m from the sewage outfall of Mar del Plata city. Caulleriella galeanoi sp. nov. is characterized by a peristomium with three annulations dorsally, with grooved palps arising from annulus 3, and by smooth capillary chaetae in noto- and neuropodia of chaetigers 1-2. Bidentate hooks are present in neuropodia from chaetiger 3, numbering 5-6 in anterior and middle chaetigers, 1-3 in posterior ones. Notopodia have 3-6 pairs of smooth capillary chaetae, decreasing in number posteriorly. From chaetiger 13-20, notopodia with 1-2 capillary chaetae and 1-2 bidentate hooks. Specimens held in aquaria supplied with water and the green alga Vaucheria sp. (Vaucheriaceae) from the intertidal zone reproduced asexually by fission. Gametes were not observed in any specimens.

Oligochaetes (Annelida, Clitellata) in a neotropical stream: a mesohabitat approach

This paper analyses the relationship among mesohabitat and aquatic oligochaete species in the Galharada Stream (Campos do Jordão State Park, state of São Paulo, Brazil). Between August 2005 and May 2006 a total of 192 samples were obtained in areas of four different mesohabitats: riffle leaf litter (RL), pool leaf litter (PL), pool sediment (PS) and interstitial sediment from rocky beds in riffle areas (IS). In the mesohabitats sampled, 2007 specimens were identified, belonging to two families (Naididae and Enchytraeidae). Among the oligochaetes identified Naididae was represented by six genera (Allonais, Chaetogaster, Nais, Pristina, Aulodrilus and Limnodrilus). Principal components analysis (PCA) revealed the first two axes explained 85.1% of the total variance of the data. Limnodrilus hoffmeisteri Claparede, 1862 and Aulodrilus limnobius Bretscher, 1899 were associated with the pool areas (PL and PS). Most species of genera Pristina and Nais demonstrated apparent affinity with the riffle mesohabitats. The Indicator Species Analysis (IndVal) revealed that Nais communis Piguet, 1906, Pristina leidyi Smith, 1896 and Pristina (Pristinella) jenkinae (Stephenson, 1931) are indicative of RL mesohabitat, while family Enchytraeidae was considered indicative of PL mesohabitat.

Miocardite no macaco Cebus após inoculações repetidas com Schizotrypanum cruzi

Transmission of Chagas disease is realized through contamination of ocular conjunctiva, mucosa or skin with infected dejections eliminated by the insect vectors of Schizotrypanum cruzi (Triatoma infestans, Panstrongylus megistus and Rhodnius prolixus). The triatomid bugs live in holes and craks in the walls, in beds, behind trunks, etc. Found in primitive mud huts covered with thatched roofs, and so the human dwellers have many chances to contract the disease, reinfections being reasonably more to expect than a single inoculation. Experimental work reproducing those natural conditions is welcomed as some important features in the pathologic picture of the disease such as the extensive myocardial fibrosis seen in chronic cases are still incompletely known. Microscopic changes were studied in the heart muscle of seven Cebus monkeys infected by S. cruzi. This animal survives the acute stage of the disease and so is particularly suited to experiments of long duration in which several inoculations of S. cruzi are performed. Three different strains of S. cruzi isolated from acute cases of Chagas' disease were employed. One monkey was injected in the skin with infected blood and necropsied after 252 days. Two monkeys were three times, and one, eight times infected in skin, one of them with contaminated blood, and two with contaminated blood and dejections from infected bugs. The necropsies were performed after 35, 95 and 149 days. One monkey was three times inoculated through the intact ocular conjunctiva (one time with infected blood, two times with dejections from infected bugs), and one time through the wounded buccal mucosa, and necropsied after 134 days. Another monkey was six times inoculated, four times through the intact ocular conjunctiva (one time with contaminated blood, three times with dejections from infected bugs) and two times injected in the skin with infected blood, and necropsied after 157 days. Finally, another monkey was nine times inoculated, four times through the intact ocular conjunctiva (one time with infected blood, and three times with dejections from infected bugs), and five times injected in the skin (four times with contaminated blood, and one time with dejections from infected bugs), and necropsied after 233 days. The microscopic picture was uniform presenting, however, considerable individual variations, and was represented by diffuse interstitial myocarditis, frequently more (marked in the right ventricle base of the heart), accompanied by lymphatic stasis. The infiltration consists of macrophages, plasma cells and lymphocytes, the cellular reaction having sometimes a perivascular distribution, involving the auriculo-ventricular system of conduction, endocardium, epicardium and cardiac sympathetic gangliae. The loss of cardiac muscle fibers was always minimal. Leishmanial forms of S. cruzi in myocardial fibers are scanty and, in two cases, absent. Fatty necrosis in the epicardium was noted in two cases. Obliterative changes of medium-sized branches of coronary arteries (hypersensitivity reaction?) and multiple infarcts of the myocardium was found in one instance. The diffuse myocarditis induced by S. cruzi in several species of monkeys of the genus Cebus observed after 233 days (several inoculations) and 252 days (single inoculation) is not associated with disseminated fibrosis such as is reported in chronic cases of Chagas' disease. Definite capacity of reversion is another characteristic of the interstitial myocarditis observed in the series of Cebus monkeys here studied. The impression was gained that repeated inoculation with S. cruzi may influence the myocardial changes differently according to the period between the reinoculations. A short period after the first inoculation is followed by more marked changes, while long periods are accompanied by slight changes, which suggests an active immunisation produced by the first inoculation. More data are required, however before a definite statement is made on this subject considering that individual variations, the natural capacity of reversion of the interstitial myocarditis and the employement of more than a species of Cebus monkeys probably exerts influence also in the results here reported.

Optimization and inhibition of the adherent ability of Plasmodium falciparum-infected erythrocytes

The vast majority of the 1-2 million malaria associated deaths that occur each year are due to anemia and cerebral malaria (the attachment of erythrocytes containing mature forms of Plasmodium falciparum to the endothelial cells that line the vascular beds of the brain). A "model" system"for the study of cerebral malaria employs amelanotic melanoma cells as the "target"cells in an vitro cytoadherence assay. Using this model system we determined that the optimum pH for adherence is 6.6 to 6.8, that high concentrations of Ca²* (50mM) result in increased levels of binding, and that the type of buffer used influences adherence (Bis Tris > MOPS > HEPES > PIPES). We also observed that the ability of infected erythrocytes to cytoadhere varied from (erythrocyte) donor to donor. We have produced murine monoclonal antibodies against P. falciparum-infected red cells which recognized modified forms of human band 3; these inhibit the adherence of infected erythrocytes to melanoma cells in a doso responsive fashion. Antimalarials (chloroquine, quinacrine, mefloquine, artemisinin), on the other hand, affected adherence in an indirect fashion i.e. since cytoadherence is due, in part to the presence of knobs on the surface of the infected erythrocyte, and knob formation is dependent on intracellular parasite growth, when plasmodial development is inhibited so is knob production, and consequently adherence is ablated.

Rotaviruses as a cause of nosocomial, infantile diarrhoea in Northern Brazil: pilot study

Faecal samples were obtained from 190 children, aged 0 to 5 years, admitted to a public hospital in Belém, Pará, Brazil. These patients were placed in a pediatric ward with 40 beds distributed in six rooms. Case were classified into three groups: (a) nosocomial: children who developed gastroenteritis 72 hr or later after admission; (b) community-acquired: patients admitted either with diarrhoea or who had diarrhoea within 72 hr following admission; (c) non-diarrhoeic: those children who had no diarrhoea three days before and three days after collection of formed faecal sample. Specimens were routinely processed for the presence of rotaviruses, bacteria and parasites. Rotaviruses were detected through enzyme-linked immunosorbent assay (ELISA) and subsequently serotyped/electrophoretyped. Rotaviruses were the most prevalent enteropathogens among nosocomial cases, accounting for 39 % (9/23) of diarrhoeal episodes; on the other hand, rotaviruses ocurred in 8.3 % (11/133) and 9 % (3/34) of community-acquired and non-diarrhoeic categories, respectively. Mixed infections involving rotavirus and Giardia intestinalis and rotavirus plus G. intestinalis and Entamoeba histolytica were detected in frequencies of 8.6 and 4.3 %, respectively, in the nosocomial group. The absence of bacterial pathogens in this category, and the unusual low prevalence of these agents in the other two groups may reflect the early and routine administration of antibiotics following admission to this hospital. Rotavirus serotype 2 prevailed over the other types, accounting for 77.8 % of isolates from nosocomial diarrhoeal episodes. In addition, at least five different genomic profiles could be observed, of which one displayed an unusual five-segment first RNA cluster. Dehydration was recorded in all cases of hospital-acquired, rotavirus-associated diarrhoea, whereas in only 57 % of nosocomial cases of other aetiology. It was also noted that nosocomial, rotavirus-associated diarrhoeal episodes occur earlier (7 days), following admission, if compared with those hospital-acquired cases of other aetiology (14 days).

Role of two Triatoma (Hemiptera: Reduviidae: Triatominae) species in the transmission of Trypanosoma cruzi (Kinetoplastida: Trypanosomatidae) to man in the West Coast of Mexico

From August 1997 to August 1998, 334 specimens of Triatoma longipennis and 62 of T. picturata were collected in four groups of localities placed in the zone from Guadalajara, Jalisco to Tepic, Nayarit, in the West Coast of Mexico. Most T. longipennis were collected outdoors (69.2%) while most T. picturata (58.1%) were collected indoors. All collected specimens were examined for Trypanosoma cruzi infection, which was detected on 98 (29.3%) T. longipennis and 17 (27.4%) T. picturata. This study confirms the role of T. longipennis and T. picturata as some of the main T. cruzi vectors to humans in Mexico. Habitation Infestation Rate with T. longipennis was of 0.09 and with T. picturata was of 0.03 and the predominating ecotopes were pile of blocks, chicken coops, pigsties, wall crawls and beds.

Invading freshwater snails and biological control in Martinique Island, French West Indies

Eight alien freshwater snail species were introduced into Martinique Island during the last 50 years. The introduced snails include four planorbids (Biomphalaria straminea, Helisoma duryi, Amerianna carinata and Gyraulus sp.), three thiarids (Melanoides tuberculata, M. amabilis and Tarebia granifera) and one ampullarid (Marisa cornuarietis). Four of these species rapidly colonized the whole Martinican hydrographic system whereas the other four remained restricted to some particular sites. The invasion processes were documented during the last 20 years and showed (i) a rapid invasion of the island by several morphs of M. tuberculata at the beginning of the 80's; (ii) the introduction of T. granifera in 1991 and M. amabilis in 1997; and (iii) the rapid spread of these last two species throughout the island. In the years following its introduction, M. tuberculata was used in biological control experiments against the snail hosts of schistosomiasis, B. glabrata and B. straminea. Experiments were conducted with success in several groups of water-cress beds which constituted the latest transmission sites for schistosomiasis at the beginning of the 80's. A malacological survey carried out in 2000 all over the island showed the absence of B. glabrata but the presence of some residual populations of B. straminea. Long-term studies carried out in Martinique have shown that the thiarids are able to maintain relatively stable populations over a long period of time, thus preventing recolonization by the snail hosts. Within this context the invasion of the hydrographic system of Martinique by thiarid snails has resulted in an efficient and sustainable control of the intermediate hosts of schistosomiasis.

Small intestinal inflammation following oral infection with Toxoplasma gondii does not occur exclusively in C57BL/6 mice: review of 70 reports from the literature

Small intestinal immunopathology following oral infection with tissue cysts of Toxoplasma gondii has been described in C57BL/6 mice. Seven days after infection, mice develop severe small intestinal necrosis and succumb to infection. The immunopathology is mediated by local overproduction of Th1-type cytokines, a so-called "cytokine storm". The immunopathogenesis of this pathology resembles that of inflammatory bowel disease in humans, i.e., Crohn's disease. In this review, we show that the development of intestinal pathology following oral ingestion of T. gondii is not limited to C57BL/6 mice, but frequently occurs in nature. Using a Pubmed search, we identified 70 publications that report the development of gastrointestinal inflammation following infection with T. gondii in 63 animal species. Of these publications, 53 reports are on accidental ingestion of T. gondii in 49 different animal species and 17 reports are on experimental infections in 19 different animal species. Thus, oral infection with T. gondii appears to cause immunopathology in a large number of animal species in addition to mice. This manuscript reviews the common features of small intestinal immunopathology in the animal kingdom and speculates on consequences of this immunopathology for humankind.

New record of Pterotaenia fasciata (Wiedemann) (Diptera, Ulidiidae) in Brazil, a probably mechanical vector of enteric bacteria

Pterotaenia fasciata is commonly recorded in rural areas in Argentina, but during a Diptera survey study developed in a reservoir which retains storm water from polluted canals in an urban area of Taboão da Serra municipality, SP, Brazil, we could capture P. fasciata adults. Enteric bacteria Escherichia coli T. Escherich, 1885 and Proteus sp. were isolated from P. fasciata collected in traps inside the reservoir and around it. Fecal coliforms and E. coli were found in the water of the reservoir. These records suggest that a high abundance of this species at urban areas with inadequate sewage canals should reveal these muscoid dipterans as mechanical vectors of enteric bacteria.

Macropropagation and micropropagation of Ziziphus spina-christi

Christ's thorn (Ziziphus spina-christi (L.) Desf.) is a cross-pollinated plant with a wide range of genetic variability in nature and, for this reason, vegetative propagation assumes importance for improvement programs. The objective of this work was to evaluate cutting, T budding and tissue culture methods for this species. Shoots of 22-25 cm length were treated by two culture media and three shoot diameters for cutting trial. The T budding treatments consisted of three and five collection dates in spring and autumn, respectively. Tissue culture nodal segments bearing axillary buds were removed from shoots of mature trees at different seasons. Experiments to determine the best disinfectant chemical, appropriate conditions and materials to prevent phenolic compound exudation, explant characteristics, media type and cytokinin-auxin ratios were carried out. Successful rooting happened only on the sand beds and with cuttings greater than 8 mm diameter. The effects of T budding seasons on budtake percentage were significantly different. The best time for explant harvesting was mid of summer. Amount of rooting on media containing IBA as well as activated charcoal and disinfection with Ca(OCl)2 at concentration of 5% for 20 minutes were the best treatments.