Infective endocarditis: a retrospective cohort study.

BACKGROUND: Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high. AIM: To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre. DESIGN: Retrospective cohort study. METHODS: Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries. RESULTS: Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications. CONCLUSIONS: This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Connecting structurally and dynamically detected signatures of supramolecular Debye liquids.

The monohydroxy alcohol 2-ethyl-1-hexanol mixed with the halogen-substituted alkyl halides 2-ethyl-1-hexyl chloride and 2-ethyl-1-hexyl bromide was studied using synchrotron-based x-ray scattering. In the diffraction patterns, an oxygen-related prepeak appears. The concentration dependence of its intensity, shape, and position indicates that the formation of the hydrogen-bonded associates of monohydroxy alcohols is largely hindered by the halogen alkane admixture. Using dielectric spectroscopy and high-resolution rheology on the same liquid mixtures, it is shown that these structural features are correlated with the relaxation mechanisms giving rise to supramolecular low-frequency dynamics.

Polaron-induced lattice distortion of (In,Ga)As/GaAs quantum dots by optically excited carriers.

We report on a high resolution x-ray diffraction study unveiling the effect of carriers optically injected into (In,Ga)As quantum dots on the surrounding GaAs crystal matrix. We find a tetragonal lattice expansion with enhanced elongation along the [001] crystal axis that is superimposed on an isotropic lattice extension. The isotropic contribution arises from excitation induced lattice heating as confirmed by temperature dependent reference studies. The tetragonal expansion on the femtometer scale is tentatively attributed to polaron formation by carriers trapped in the quantum dots.

Supramolecular x-ray signature of susceptibility amplification in hydrogen-bonded liquids.

Mixing two nonconducting hydrogen-bonded liquids, each exhibiting a low dielectric relaxation strength, can result in a highly electrically absorbing fluid. This susceptibility amplification effect is demonstrated for mixtures of monohydroxy alcohols. Whereas in the pure liquids a tendency to form ringlike low-dipole moment clusters prevails, in the mixtures such supramolecular structures are disfavored leading to an up to tenfold enhancement of the dielectric loss. The compositional evolution of density and mean cluster-cluster separation is traced using x-ray scattering and indicates deviations from ideal mixing with decreased C-C but simultaneously increased O-O correlation lengths. Thus, the variation in the supramolecular absorption strength could be tracked using a static scattering technique. These observations are in harmony with volume exclusion and ring open effects that predict an optimized susceptibility amplification for mixtures in which the two components occupy equal volume fractions as experimentally observed.

Intermolecular interactions in highly concentrated protein solutions upon compression and the role of the solvent.

The influence of high hydrostatic pressure on the structure and protein-protein interaction potential of highly concentrated lysozyme solutions up to about 370 mg ml(-1) was studied and analyzed using small-angle X-ray scattering in combination with a liquid-state theoretical approach. In the concentration region below 200 mg ml(-1), the interaction parameters of lysozyme solutions are affected by pressure in a nonlinear way, which is probably due to significant changes in the structural properties of bulk water, i.e., due to a solvent-mediated effect. Conversely, for higher concentrated protein solutions, where hydration layers below ∼4 water molecules are reached, the interaction potential turns rather insensitive to compression. The onset of transient (dynamic) clustering is envisaged in this concentration range. Our results also show that pressure suppresses protein nucleation, aggregation and finally crystallization in supersaturated condensed protein solutions. These findings are of importance for controlling and fine-tuning protein crystallization. Moreover, these results are also important for understanding the high stability of highly concentrated protein solutions (as they occur intracellularly) in organisms thriving under hydrostatic pressure conditions such as in the deep sea, where pressures up to the kbar-level are reached.

Renal cell carcinoma with IVC and atrial thrombus: a single centre's 10 year surgical experience.

UNLABELLED: Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes. PATIENTS AND METHODS: From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, peri-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival. RESULTS: We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 ± 3.5 vs. 7.2 ± 1.2 vs. 3.5 ± 1.1 h, respectively). Peri-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB). CONCLUSIONS: IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome.

Structural changes in amorphous Ge(x)SiO(y) on the way to nanocrystal formation.

Temperature induced changes of the local chemical structure of bulk amorphous GexSiOy are studied by Ge K-edge x-ray absorption near-edge spectroscopy and Si L2/3-edge x-ray Raman scattering spectroscopy. Different processes are revealed which lead to formation of Ge regions embedded in a Si oxide matrix due to different initial structures of as-prepared samples, depending on their Ge/Si/O ratio and temperature treatment, eventually resulting in the occurrence of nanocrystals. Here, disproportionation of GeOx and SiOx regions and/or reduction of Ge oxides by pure Si or by a surrounding Si sub-oxide matrix can be employed to tune the size of Ge nanocrystals along with the chemical composition of the embedding matrix. This is important for the optimization of the electronic and luminescent properties of the material.

Getting to the heart of cardiac remodeling; how collagen subtypes may contribute to phenotype.

The objective of this study was to investigate the nature and biomechanical properties of collagen fibers within the human myocardium. Targeting cardiac interstitial abnormalities will likely become a major focus of future preventative strategies with regard to the management of cardiac dysfunction. Current knowledge regarding the component structures of myocardial collagen networks is limited, further delineation of which will require application of more innovative technologies. We applied a novel methodology involving combined confocal laser scanning and atomic force microscopy to investigate myocardial collagen within ex-vivo right atrial tissue from 10 patients undergoing elective coronary bypass surgery. Immuno-fluorescent co-staining revealed discrete collagen I and III fibers. During single fiber deformation, overall median values of stiffness recorded in collagen III were 37±16% lower than in collagen I [p<0.001]. On fiber retraction, collagen I exhibited greater degrees of elastic recoil [p<0.001; relative percentage increase in elastic recoil 7±3%] and less energy dissipation than collagen III [p<0.001; relative percentage increase in work recovered 7±2%]. In atrial biopsies taken from patients in permanent atrial fibrillation (n=5) versus sinus rhythm (n=5), stiffness of both collagen fiber subtypes was augmented (p<0.008). Myocardial fibrillar collagen fibers organize in a discrete manner and possess distinct biomechanical differences; specifically, collagen I fibers exhibit relatively higher stiffness, contrasting with higher susceptibility to plastic deformation and less energy efficiency on deformation with collagen III fibers. Augmented stiffness of both collagen fiber subtypes in tissue samples from patients with atrial fibrillation compared to those in sinus rhythm are consistent with recent published findings of increased collagen cross-linking in this setting.

Traumatic tricuspid regurgitation and right-to-left intra-atrial shunt--an unusual complication of a horse-kick.

A 63-year-old male presented with sudden onset chest pain and dyspnoea following a kick to the praecordium while gelding a horse. Transthoracic echocardiography showed evidence of flail tricuspid valve leaflets, severe tricuspid regurgitation and a widely patent foramen ovale with a right-to-left shunt. Due to progressive severe systemic hypoxemia the patient underwent emergent surgical intervention. Operative findings confirmed rupture of the anterior and septal tricuspid valve papillary muscles. Successful papillary muscle reattachment was performed in association with tricuspid annuloplasty and suture closure of his patent foramen ovale. Disruption of the tricuspid valve is well described as consequence of blunt trauma to the chest wall and is often well tolerated, coming to light many years post injury. Valve disruption due to rupture at the papillary muscle level, however, typically results in greater severity of tricuspid regurgitation and the abrupt rise in right intra-atrial pressure may lead to a right-to-left shunt across a patent foramen ovale. Where hemodynamic compromise ensues, prompt surgical intervention is mandated.

Synchronous lung tumours in a patient with metachronous colorectal carcinoma and a germline MSH2 mutation.

Mutations of DNA mismatch repair genes are characterised by microsatellite instability and are implicated in carcinogenesis. This mutation susceptible phenotype has been extensively studied in patients with hereditary non-polyposis colon carcinoma, but little is known of the contribution of such mutations in other tumour types, particularly non-small-cell lung carcinoma. This report describes the occurrence of two synchronous lung tumours, one mimicking a metastatic colon carcinoma, in a male patient with a history of metachronous colonic carcinoma. Immunohistochemistry supported a pulmonary origin for both lesions. Mismatch repair protein immunohistochemistry showed loss of MSH2 and MSH6 expression in both colonic tumours and in one lung tumour showing enteric differentiation. Subsequent mutational analysis demonstrated a deleterious germline mutation of the MSH2 mismatch repair gene. The significance of these findings and the practical diagnostic difficulties encountered in this case are discussed.

Lack of correlation between smoking status and early postoperative outcome following valve surgery.

BACKGROUND: We sought to assess the effect of smoking on early outcome following valve surgery. METHODS: This is a retrospective review of a prospectively collected departmental database of all patients who underwent isolated aortic and/or mitral valve surgery (replacement and/or repair). Our cohort consisted of 590 patients stratified into three groups: current smokers (n = 94), ex-smokers (n = 243), and nonsmokers (n = 253). RESULTS: There were no significant differences in the in-hospital mortality between the three groups. Likewise, the length of both hospital and intensive care unit stays were similar among the three groups with a similar rate of postoperative complications. These findings remained statistically not significant, even after adjusting for potential confounders such as age, gender, etc. CONCLUSION: Smoking does not seem to be associated with an increased early postoperative risk in patients undergoing valve surgery. However, because of the known effect of smoking on the risk of cardiovascular disease and because the effect of smoking on long-term survival in patients undergoing valve surgery remains unknown, patients should still be encouraged to quit smoking.

An extraction algorithm for core-level excitations in non-resonant inelastic X-ray scattering spectra.

Non-resonant inelastic X-ray scattering of core electrons is a prominent tool for studying site-selective, i.e. momentum-transfer-dependent, shallow absorption edges of liquids and samples under extreme conditions. A bottleneck of the analysis of such spectra is the appropriate subtraction of the underlying background owing to valence and core electron excitations. This background exhibits a strong momentum-transfer dependence ranging from plasmon and particle-hole pair excitations to Compton scattering of core and valence electrons. In this work an algorithm to extract the absorption edges of interest from the superimposed background for a wide range of momentum transfers is presented and discussed for two examples, silicon and the compound silicondioxide.

Partially wetting thin liquid films: structure and dynamics studied with coherent x rays.

We studied the surface structure of thin liquid films vapor deposited on solid substrates in a partial wetting situation by means of coherent x-ray scattering. No dynamics has been observed showing the absence of capillary waves on liquid films partially wetting a substrate. Instead an exponential form of the height-height correlation function has been found pointing toward a solidlike behavior of the thin liquid films at large length scales. The exact surface structure and degree of replication with the substrate depend on the deposition rate of the molecules.

Two-dimensional dynamics of metal nanoparticles on the surface of thin polymer films studied with coherent X rays.

X-ray photon-correlation spectroscopy is used to measure the dynamic structure factor f(q,tau) of gold particles moving on the surface of thin polymer films. Above the glass transition of the polymer the peculiar form f(q,tau) approximately exp[-(Gamma tau)(alpha)] is found with 0.7 < alpha < 1.5, depending on sample age and temperature. The relaxation rates Gamma scale linearly with q, excluding a simple Brownian diffusive motion. This type of behavior, already observed in aging bulk soft matter systems, is explained by a power law distribution of particle velocities due to ballistic motion.

Deviations from liquidlike behavior in molten polymer films at interfaces.

We have performed x-ray specular and diffuse scattering on liquid polymer films and analyzed the spectra as a function of film thickness and molecular weight. The results show that films whose molecular weight is close to the entanglement length behave as simple liquids except that the shortest wavelength is determined by the radius of gyration (R(g)) rather than the monomer-monomer distance. When the molecular weight is higher than the entanglement length, the strong deviations from liquidlike behavior are observed. We find that the long wavelength cutoff vector, q(l,c), scales with film thickness, d as d(-1.1+/-0.1) rather than the usual d(-2) expected for simple liquids. If we assume that these deviations are due to surface pinning of the polymer chains, then our results are consistent with the formalism developed by Fredrickson et al. to explain the capillary wave spectrum that can propagate in a polymer brush.

Surface roughness and adsorption isotherms of molecularly thin liquid films: an x-ray reflectivity study.

We present an x-ray reflectivity study of molecularly thin films of liquid isobutane adsorbed on liquid glycerol. The glycerol-isobutane interface serves as a model system to investigate the influence of the substrate adsorbate interactions on both adsorption isotherms and capillary wave fluctuations. The measured surface roughness is smaller than expected from the harmonic approximation of the interaction potential. Expressions for the surface roughness in slightly anharmonic potentials are given and compared to the experimental data. A good agreement between data and theory is achieved.

Surface roughness of supercooled polymer melts.

We report on in situ x-ray reflectivity measurements of the surface roughness of supercooled glass forming polymers in a temperature range from 190 to 330 K. The experimentally determined rms roughness has been found to obey the capillary wave model of a single liquid/vapor interface over the entire temperature range. An expression for the surface roughness below the bulk glass transition (T(G) approximately equal to 200 K) is deduced from the viscoelastic theory of surface fluctuations; however, no indication of a frozen-in surface roughness has been observed in the experiment. Additionally, it is shown that precise values of the surface tension of highly viscous liquids in the supercooled state can be determined by x-ray reflectivity.

Phase behaviour of n-hexane/perfluoro-n-hexane binary thin wetting films.

We present X-ray reflectivity investigations of the concentration distribution in binary liquid thin films on silicon substrates. The liquid-vapor coexistence of the binary mixture investigated, hexane and perfluorohexane, is far from criticality. Therefore, a sharp interface separates the liquid film from the vapor. The data reveal a separation of the film in layers parallel to the substrate. A phase diagram is constructed as a projection to the (composition difference, temperature) space, covering a temperature range corresponding to the one-phase and the two-phase regime of the bulk liquid. Although the composition data indicate a mixing gap similar to that of the bulk system, there are two major differences: i) only the near-surface phase changes its composition significantly, and ii) a composition gradient in the film exists also at higher temperatures where in the bulk system the one-phase regime exists.

Capillary waves at the transition from propagating to overdamped behavior.

We measure the dispersion relation of capillary waves on a liquid surface by heterodyne x-ray photon correlation spectroscopy near the transition from propagating to overdamped dynamic behavior. A strong deviation of the propagation frequency from the small-damping result omega(p) proportional, variant k(3/2) is observed long before the actual transition where ( partial differential omega(p)/ partial differential k)<0 and omega(p) tends to zero. This behavior is successfully described by expressions derived within linear response theory.