The pesticides use and the risk for head and neck cancer: A review of case-control studies.

BACKGROUND: Tobacco, alcohol consumption, and HPV infection are the most common risk factors for head and neck cancer (HNC). Despite of this, recent evidences are growing on the association between long-term exposure to pesticides and the risk of chronic diseases, including different types of cancer. The present review evaluated in current literature evidence of an association between exposure to pesticides and the occurrence of HNCs. MATERIAL AND METHODS: A literature search of the case-control studies was conducted in the PubMed, Web of science and Cochrane databases. Methodological quality of each study was rated with the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. RESULTS: One thousand and thirty-five studies were identified and twelve met all criteria and, therefore, considered for quality assessment and data extraction. According to SIGN 50 criteria, six studies received an overall high-quality. All the studies considered of high quality found a positive association between exposure to pesticides and different HNC sites, including larynx, pharynx and nasal cavity. In addition, the increased risk was associated with the frequency of exposure. CONCLUSIONS: Finally, improving pesticide users' awareness of their risks and proper handling, as well as adopting protective measures such as the use of personal protective equipment, appear to be effective in reducing human health damage.

Awareness on oral cancer among patients attending dental school clinics in Brazil.

BACKGROUND: Oral cancer is considered a public health problem worldwide. Dental schools may play an important role in educating patients about oral cancer. This study aimed at evaluating the knowledge of patients attending clinics at two dental schools in Brazil. MATERIAL AND METHODS: From March 2017 to April 2017, 251 patients who were attending clinics at two dental schools in Recife, Brazil, were included in the study. Patients were contacted in the waiting rooms of the clinic. Each participant completed a self-administered questionnaire, which consists of 21 questions, including socio-demographic and specific information on the disease. Data were analyzed using descriptive statistics, and a chi-square test (with a 5% significance level) was used to assess the correlation between the variables, education and family income and other variables. RESULTS: Most participants were women (64.9%) with a mean age of 42.72 years. Most participants were knowledgeable about oral cancer and identified tobacco use (48.6%), alcohol consumption (25.1%), and solar radiation (12%) as the primary risk factors for the disease. Only 36.7% of the participants reported having received counselling on oral cancer, of which 18.3% received the information from a dentist. All patients with an income higher than six minimum wages were aware about oral cancer (p = 0.001). CONCLUSIONS: These findings emphasize the importance of educational programs in dental schools as well providing integrated services for patients seeking care at school clinics, including population's awareness on oral cancer.

[Transcatheter aortic valve replacement]. / Remplacement valvulaire aortique percutané.

After more than ten years of development, A. Cribier accomplished in 2002 the first percutaneous aortic valve replacement (AVR), which is a curative procedure for severe aortic stenosis and an alternative to surgery for high risk patients. With material improvements over time, the procedure has evolved to become a purely percutaneous intervention in most centers. Currently, two different valve systems, the CoreValve Revalving system and the Edwards SAPIEN valve, have each been implanted in more than 1,500 patients. Careful patient selection, including consideration of vascular access, associated cardiomyopathies and annulus size, remains critical. Although this technique has generated great enthusiasm, conventional surgery remains the gold standard in late 2008.

Randomized, double-blind, multicenter study of the Endeavor zotarolimus-eluting phosphorylcholine-encapsulated stent for treatment of native coronary artery lesions. Clinical and angiographic results of the ENDEAVOR II Trial.

AIM: The use of the Endeavor stent might reduce restenosis and stent thrombosis at 9 months. METHODS: Patients (n =1,197) treated for single coronary artery stenosis were enrolled in a prospective, randomized, double-blind study and randomly assigned to receive the Endeavor zotarolimus-eluting phosphorylcholine polymer-coated stent (n= 598) or the same bare metal stent but without the drug or the polymer coating (n=599). RESULTS: The 2 groups were well matched in baseline characteristics. Diabetes was present in 20.1% of patients; the mean reference vessel diameter was 2.75 mm; and the mean lesion length was 14.2 mm. The primary end point of target vessel failure at 9 months was reduced from 15.1% with the bare metal stent to 7.9% with the Endeavor (P=0.0001), and the rate of major adverse cardiac events was reduced from 14.4% with the bare metal stent to 7.3% with the Endeavor (P=0.0001). Target lesion revascularization was 4.6% with Endeavor compared with 11.8% with the bare metal stent (P=0.0001). The rate of stent thrombosis was 0.5% with the Endeavor, which was not significantly different from 1.2% with the bare metal stent. In 531 patients submitted to angiographic follow-up, late loss was reduced from 1.03+/-0.58 to 0.61+/-0.46 (P<0.001) in stent and from 0.72+/-0.61 to 0.36+/-0.46 (P<0.001) in segment. The rate of in-segment restenosis was reduced from 35% to 13.2% with Endeavor (P<0.0001). There was no excessive edge stenosis, aneurysm formation, or late acquired malposition by intravascular ultrasound imaging. Differences in clinical outcome were maintained at 12 and 24 months (P<0.0001). CONCLUSIONS: Compared with bare metal stents, the Endeavor stent is safe and reduces the rates of clinical and angiographic restenosis at 9, 12, and 24 months.

BRAVO I: A pilot study of vascular brachytherapy in polytetrafluoroethylene dialysis access grafts.

Hemodialysis vascular access dysfunction owing to stenosis and thrombosis in polytetrafluoroethylene dialysis access grafts is a huge clinical problem for which there are currently no long lasting durable therapies. Vascular brachytherapy has been used successfully for the prevention of coronary restenosis following angioplasty and stent placement. The Beta Radiation for Treatment of Arterial-Venous Graft Outflow I study was a pilot study of vascular brachytherapy in hemodialysis patients with patent but dysfunctional grafts. Twenty-five patients were randomized to receive either radiation therapy (a single dose of 18.4 Gy) or sham radiation, following angioplasty. The primary efficacy end point of the study was target lesion primary patency at 6 months. The primary safety end point was a composite of death, emergency surgery on the graft, venous rupture, or aneurysm formation. Forty-two percent of the radiated grafts achieved the target lesion primary patency end point at 6 months as compared to 0% of the control group (P = 0.015), but this did not translate into an improvement in secondary patency at either 6 or 12 months. Radiation therapy was found to be safe in the setting of hemodialysis vascular access dysfunction. Our results suggest that vascular brachytherapy is an intervention that is worthy of further examination in the setting of non-thrombosed dialysis access grafts.

Clinical and angiographic acute and follow up results of intracoronary beta brachytherapy in saphenous vein bypass grafts: a subgroup analysis of the multicentre European registry of intraluminal coronary beta brachytherapy (RENO).

OBJECTIVE: To assess clinically and angiographically the feasibility, safety, and effectiveness of vascular brachytherapy (VBT) in saphenous vein bypass grafts (SVG). PATIENTS AND METHODS: 67 of 1098 (6.1%) consecutive patients of the European registry of intraluminal coronary beta brachytherapy underwent treatment for 68 SVG lesions by VBT using a Sr/Y(90) source train (BetaCath). Clinical follow up data were obtained for all of them after a mean (SD) of 6.3 (2.4) months and angiographic follow up was performed in 61 patients (91.0%) after 6.9 (2.0) months. RESULTS: 58 (86.6%) patients were men, their mean (SD) age was 66 (10) years, 28 (41.8%) had unstable angina, and 21 (31.3%) had diabetes. Fifty three (77.9%) lesions were in-stent restenosis, 13 (19.1%) de novo lesions, and 2 (3.0%) non-stented restenotic lesions. Mean (SD) reference diameter before the intervention was 4.19 (0.52) mm, mean (SD) lesion length was 23.56 (20.38) mm, and mean (SD) minimum lumen diameter measured 0.73 (0.62) mm. Mean (SD) acute gain was 3.02 (0.88) mm. The prescribed radiation dose was 20.1 (3.2) Gy. Pullback manoeuvres were performed in 17 (25.0%) of cases. Most patients received combined aspirin and thienopyridin treatment for 6 or 12 months after the procedure. Technical success was obtained in 62 (91.2%) treated lesions and in-hospital major adverse cardiac events occurred in 4.5%. At follow up, mean (SD) reference diameter was 4.20 (0.53) mm, minimum lumen diameter 2.94 (1.50) mm, and late loss 0.86 (1.25) mm. The overall major adverse cardiac events rate was 26.7%. CONCLUSION: VBT of SVG is feasible and safe. At follow up the reintervention rate and cardiac morbidity and mortality seem to be favourable, considering that interventions in SVG usually are associated with the highest risks.

A multicentre European registry of intraluminal coronary beta brachytherapy.

AIMS: To assess the feasibility, safety and effectiveness of intravascular brachytherapy (VBT) in routine clinical practice. METHODS AND RESULTS: Between April 1999 and September 2000, 1098 consecutive patients treated in 46 European centres by intraluminal irradiation using a Sr/Y(90)source train (BetaCath, Novoste, GA) were included in a registry, and follow-up data were obtained for 98.8% of them after 6.3+/-2.4 months. Eight hundred and forty (76.5%) patients were males, and mean age was 62.0+/-10.2 years. Two hundred and seventy-one (26.9%) had unstable angina, and 256 (23.5%) were diabetics. Nine hundred and thirteen lesions (77.7%) were the result of in-stent restenosis, 208 (17.7%) were de novo lesions and 48 (4.1%) non-stented restenotic lesions. Mean estimated reference diameter was 3.2+/-0.5mm and mean estimated lesion length was 19.0+/-11.8mm. The prescribed radiation dose was 18.8+/-3.2Gy. Multivessel irradiation was done in 6.2% of cases, and a new stent was implanted in 29.6% of cases. Most patients received 6 or 12 months of combined aspirin and thienopyridin treatment after the procedure. Technical success was obtained in 95.9% of treated lesions, and the in-hospital major adverse cardiac event (MACE) rate was 1.8%. At follow-up, the MACE rate was 18.7% (1.9% deaths from any cause, 2.6% AMI, 13.3% TVR by PCI and 3.3% TVR by CABG). CONCLUSION: The major current application of VBT is the treatment of in-stent restenosis. The good results of VBT observed in recent randomized controlled trials can be reproduced in clinical practice.

Reno, a European postmarket surveillance registry, confirms effectiveness of coronary brachytherapy in routine clinical practice.

PURPOSE: To assess, by a European registry trial, the clinical event rate in patients with discrete stenotic lesions of coronary arteries (de novo or restenotic) in single or multiple vessels (native or bypass grafts) treated with beta-radiation. MATERIALS AND METHODS: Between April 1999 and September 2000, 1098 consecutive patients treated in 46 centers in Europe and the Middle East with the Novoste Beta-Cath System were included in Registry Novoste (RENO). RESULTS: Six-month follow-up data were obtained for 1085 patients. Of 1174 target lesions, 94.1% were located in native vessels and 5.9% in a bypass graft; 17.7% were de novo lesions, 4.1% were restenotic, and 77.7% were in-stent restenotic lesions. Intravascular brachytherapy was technically successful in 95.9% of lesions. Multisegmental irradiation, using a manual pullback stepping maneuver to treat longer lesions, was used in 16.3% of the procedures. The in-hospital rate of major adverse cardiac events was 1.8%. At 6 months, the rate was 18.7%. Angiographic follow-up was available for 70.4% of the patients. Nonocclusive restenosis was seen in 18.8% and total occlusion in 5.7% of patients. A combined end point for late (30-180 days) definitive or suspected target vessel closure was reached in 5.4%, but with only 2% of clinical events. Multivariate analysis was performed for major adverse cardiac events and late thrombosis. CONCLUSIONS: Data obtained from the multicenter RENO registry study, derived from a large cohort of unselected consecutive patients, suggest that the good results of recent randomized controlled clinical trials can be replicated in routine clinical practice.

High-dose intravascular beta-radiation after de novo stent implantation induces coronary artery spasm.

BACKGROUND: Intracoronary brachytherapy is effective in preventing restenosis after coronary interventions. However, in vitro and animal studies have shown that irradiation produces immediate and sustained endothelial dysfunction. This study assesses the clinical relevance of impaired vasomotoric function induced by brachytherapy. METHODS AND RESULTS: We analyzed the occurrence of postradiation coronary artery spasms in 1 animal study and 2 clinical trials investigating the effects of high-dose intracoronary beta-radiation after de novo coronary artery stenting. Irradiated segments (IRSs) proximal and distal to the stent were studied by quantitative coronary angiography after stenting, after radiation, and at the end of the procedure. There was an 67% overall incidence of coronary artery spasm in the IRSs immediately after beta-radiation compared with 9% after sham treatment (P<0.001). Whereas in most cases this phenomenon was only minor or moderate, in 12 cases, 4 (22%) animals and 8 (28%) patients, severe coronary spasm (>90% diameter stenosis) with significant ECG-changes or hemodynamic instability was observed. Relief of spasms was protracted (mean time until complete relief of spasm 423+/-122 seconds) and required repetitive intracoronary administration of nitroglycerin (mean dose: 1.2+/-0.6 mg). CONCLUSIONS: Vasoconstriction is a frequent reaction of coronary arteries after high-dose intracoronary beta-radiation, necessitating repetitive administration of vasodilators.

Impact of final coronary flow velocity reserve on late outcome following stent implantation.

Aims To assess whether coronary flow velocity reserve following stent implantation is predictive of the subsequent need of target lesion revascularization. Methods and Results The outcome was examined of 417 patients enrolled in a multicentre prospective randomized study (DESTINI), who received a successful single vessel stent implantation in native coronary arteries and in whom coronary flow velocity reserve was measured. Logistic regression analysis and the receiver operator characteristic curve were used. When compared with 358 patients not requiring target lesion revascularization, 59 patients (14%) who underwent target lesion revascularization had a lower final coronary flow velocity reserve (2.33 +/- 0.87 vs 2.48+/- 0.80, P= 0.20) and smaller final minimal lumen diameter (2.62 +/- 0.66 mm vs 2.73+/- 0.60, P= 0.19); however, those differences were not statistically significant. Patients with a coronary flow velocity reserve of < 2.0 (n=109, 26%) exhibited a significantly higher target lesion revascularization rate than patients with a coronary flow velocity reserve of > or = 2.0 (22% vs 11%, P= 0.010). This difference remained significant (odds ratio=2.01, 95% CI=1.11 to 3.66) after adjustment for other variables that were also correlated with the incidence of target lesion revascularization. Conclusion The presence of a final coronary flow velocity reserve of < 2.0 is an independent predictor of the need for target lesion revascularization after stent implantation in native coronary artery lesions.

Treatment of long, diffuse, in-stent restenotic lesions with beta radiation using strontium 90 and sequential positioning "pullback" technique: procedural details and clinical outcomes.

BACKGROUND: Long, diffuse, in-stent restenotic lesions have been problematic for many patients, necessitating the need for multiple repeat percutaneous coronary interventions (PCI). The need for repeat PCI has been significantly reduced in patients since the advent of vascular brachytherapy. In-stent restenosis resulting in long lesions (> 30 mm) presents even more of a challenge. The interventional injury length created during PCI is usually greater than 30 mm and the vascular brachytherapy systems available in most hospitals are 30 mm or 40 mm in length. The purpose of this paper is to define "pullback technique" and to report the Montreal Heart Institute (MHI) data to show that the pullback technique using the Novoste system seems to be a safe and effective method for using vascular brachytherapy to treat long, diffuse, in-stent restenotic lesions. METHODS: We reviewed the database of patients enrolled in the Compassionate Use Registry between August 1999 and July 2000. The data are reported on 23 consecutive patients treated with the pullback technique. RESULTS: The mean lesion length was 49.4 +/- 19.8 mm. Three patients (13%) underwent target vessel revascularization. Angiographic follow-up was obtained in 18 patients (78%). Seven patients (38.8%) showed angiographic restenosis (> 50% luminal re-narrowing). No aneurysms or zones of ectasia were noted. CONCLUSION: This angiographic and clinical evaluation of the MHI Compassionate Use Registry data show the pullback technique to be safe from both a dosimetric and clinical point of view.

Coronary angiography using 4 or 6 French diagnostic catheters: a prospective, randomized study.

Diagnostic catheter size has been progressively decreased in order to reduce complications (particularly access-site complications) and permit early ambulation after coronary angiography. However, excessive down-sizing can result in poor catheter conformation and poor imaging quality of coronary angiograms (CA). This study randomly compared the accuracy and angiographic quality (QUAL) of CA performed with 4 French (Fr) vs. 6 Fr diagnostic catheters. Injections were done manually using a low-viscosity, non-heated, low-osmolality contrast media (Iomeprol). CAs were performed via the femoral approach using Judkins catheters. Handling, torque, selectively and stability were graded from 1 (excellent) to 4 (unacceptable) by the operator. QUAL was also graded from 1 (unacceptable) to 10 (excellent) by the operator in all patients and by an independent Core laboratory in 50 patients matched for gender and weight. Between January and April 1997, a total of 405 consecutive patients were randomized. Mean age was 63.4 +/- 11.1 years and 79% were male. Clinical characteristics of patients, quality of left coronary catheter and cross-over rates (1.5% with 6 Fr vs. 3.9% with 4 Fr catheters) were similar in both groups. Using the right coronary catheters, the only difference was handling, which was found to be easier with 6 Fr catheters (1.16 +/- 0.55 vs. 1.34 +/- 0.77, respectively; p = 0.007). Similarly, handling difficulty using the pigtail catheter was the only significant difference between the two groups (1.16 +/- 0.50 vs. 1.33 +/- 0.77, respectively; p = 0.009), but no cross-over was necessary in either group. The QUAL of CA was slightly but significantly better with 6 Fr than with 4 Fr catheters but considered non-diagnostic (< 7/10) in 1.4% vs. 6.8% of left CAs (p = NS). Procedural time (21.0 +/- 7.2 minutes vs. 19.0 +/- 8.1 minutes; p = 0.007) was shorter with 4 Fr catheters, but x-ray exposure, compression times and amount of contrast media used were similar. Ambulation was obtained at 2 hours in 15.1% vs. 34.0% of patients (p < 0.001) and at 4 hours in 43.8% vs. 52.4% (p < 0.05), respectively. The incidence of the worst access-site complication (moderate hematoma) was similar (1%) in both groups. CA can be performed using 4 Fr catheters and manual injections of low-viscosity contrast media with acceptable angiographic results in the majority of cases. This is associated with a shorter procedural time and earlier ambulation, and a decreased but acceptable angiographic quality.

Intravascular ultrasound assessment of pulmonary vascular disease in patients with pulmonary hypertension.

BACKGROUND: Measurements of pulmonary pressure and resistance are still considered to be the "gold standard" in the evaluation of pulmonary hypertension (PH), despite their limitations in predicting irreversible disease. Hemodynamic assessment also only provides a global evaluation of the pulmonary vascular bed, whereas PH is an inhomogeneous disease of the vessel wall. METHODS AND RESULTS: We assessed the value of intravascular ultrasound (IVUS) in 30 patients with suspected PH and correlated the structural changes in distal pulmonary arteries found on IVUS with conventional hemodynamic data. Plasma endothelin (ET)-1 levels and pulmonary ET-1 extraction also were measured as markers of the severity of PH. The anatomic abnormalities revealed by IVUS were more severe in the lower lobes than in the upper lobes, as evidenced by the greater percentage of wall thickness (WT), the smaller lumen diameter/WT and lumen area/total vessel area (p < 0.05 for each). IVUS anatomic indexes correlated directly with hemodynamic data (eg, with pulmonary arterial systolic pressure; r = 0.56; p < 0.001) and ET-1 levels but inversely with pulmonary ET-1 extraction. CONCLUSION: Patients with PH have greater pulmonary arterial WT that is more severe in the lower lobes than in the upper lobes. The severity of structural abnormalities found on IVUS is directly correlated with hemodynamic findings and ET-1 levels. IVUS may provide useful additional information in the assessment of patients with PH.

Complications of cardiac catheterization in the current era: a single-center experience.

Consecutive cardiac catheterization procedures done over a 2-yr period (April 1996 to March 1998) were prospectively analyzed to determine and characterize procedure-related complications (in-hospital and 1-mo follow-up), as they occur at present. During the study period, 11,821 procedures (7,953 diagnostic and 3,868 therapeutic) were performed. The majority of procedures (> 60%) were done in high-risk patients. Stents were implanted in 33% of patients, and adjunctive abciximab was used in 6.6% of therapeutic procedures. The overall complication rate was 8% (3.6% of diagnostic procedures and 15.1% of therapeutic procedures). The procedure-related mortality rates were 0.2%, 0.1%, and 0.5% for total, diagnostic, and therapeutic procedures, respectively. Cardiac complications were seen in 3.9% (1.5% of diagnostic and 9% of therapeutic procedures). Emergency cardiac surgery was required in 0.05% of the diagnostic procedure group and 0.3% of the therapeutic procedure group (total, 0.1%). Despite marked changes in patient population and practice, the complication rates of cardiac catheterization remain very low.