Allopurinol prevents cardiac and skeletal muscle damage in professional soccer players.

Xanthine oxidase (XO), a free radical-generating enzyme, is involved in tissue damage produced during exhaustive exercise. Our aim was to test whether allopurinol, a powerful inhibitor of XO, may be effective in preventing exercise-induced tissue damage in soccer players. Twelve soccer players were randomized into two experimental groups. One received allopurinol, before a match of the premier Spanish Football League, and the other placebo. Allopurinol prevented the exercise-induced increase in all the markers of skeletal muscle damage analyzed: creatine kinase, lactate dehydrogenase, aspartate aminotransferase, and myoglobin. Creatine kinase-MB isoenzyme and highly sensitive troponin T, specific biomarkers of myocardial injury, increased significantly in the placebo but not in the allopurinol-treated group after the football match. We also found that the exercise-induced lipid peroxidation, as reflected by malondialdehyde measurements, was prevented after allopurinol administration. However, inhibition of XO did not prevent the increment in the activity of alanine aminotransferase found after the match. No changes in the serum gamma glutamyltransferase activity was found after the match on either the placebo and the allopurinol groups. These two enzymes were determined as biomarkers of liver injury. Allopurinol represents an effective and inexpensive pharmacological agent to prevent tissue damage in soccer players.

Effects of verapamil on indexes of heart rate variability after acute myocardial infarction.

In patients with previous myocardial infarction (MI), depressed heart rate variability (HRV) may reflect a reduction in vagal activity and lead to cardiac electrical instability. Interventions designed to increase HRV may be of clinical interest. Data on the effects of calcium antagonists on HRV in post-MI patients are very limited. The aim of our study was to assess the effects of verapamil on HRV and on the sympathovagal balance after MI. Fifty consecutive patients with a first MI, stable sinus rhythm, and left ventricular ejection fraction >0.40 were studied. Each patient underwent two 24-hour Holter recordings, 1 at baseline and another after 4 days of treatment with verapamil retard (180 mg 2 times daily). Time and frequency domain parameters of HRV were analyzed. All time domain measurements increased significantly after verapamil: the standard deviation of all NN intervals (SDNN) from 87.1 +/- 31.4 to 98.1 +/- 30.3 ms (p <0.05) and the log-transformed percentage of pairs of adjacent NN intervals that differ >50 ms (pNN50) from 0.57 +/- 0.42 to 0.76 +/- 0.45 (p <0.01). The standard deviation of the averages of RR interevals (SDANN) (75.9 +/- 30.1 vs 86.3 +/- 29.4 ms, p <0.05), root-mean-square of successive differences between RR intervals (rMSSD) (23.0 +/- 11.7 and 28.1 +/- 13.1 ms, p <0.01), and the triangular HRV index (28.3 +/- 9.6 vs 23.4 +/- 8.6, p <0.001) also increased. A significant inverse correlation was found between improvement in HRV indexes induced by verapamil and baseline values. Spectral analysis showed a significant increase in high-frequency power of 58.5% without changes in low and very low components. With normalized units, significant reductions in low-frequency power and low- to high-frequency ratio were observed. Diabetic patients did not show any significant changes in HRV on administration of verapamil. These findings indicate that verapamil, administered during the subacute phase of MI, improves both global and short-period indexes of HRV and induces a shift in the sympathetic-parasympathetic interaction toward vagal predominance. This effect may contribute to an explanation of the beneficial effects of verapamil that have been reported in post-MI patients.

Early and late exercise testing. Usefulness after percutaneous transluminal coronary angioplasty.

Seventy-five patients 36 to 68 years of age were studied after undergoing successful single-vessel percutaneous transluminal coronary angioplasty (PTCA). In all cases exercise tests (ETs) were made prior to the procedure and 2 to 4 days and 6 months thereafter. Angiographic controls were performed on patients with positive ET. Both early and late ET carried out after dilatation lasted significantly longer. Patients were able to tolerate greater work loads and their heart rates and arterial blood pressures also were higher. The ETs conducted prior to PTCA were positive in 62 patients. After dilatation, the early test was positive in 18 and the late test, in 10. Angiographic controls revealed restenosis in 75 percent of patients with single-vessel disease and positive ET. Thus, the results of ETs in patients with single-vessel disease tend to become negative after successful PTCA. Early and late positive ETs are associated with restenosis, while negative ETs indicate a good prognosis.

[Recurrent syncope without angina: an uncommon presentation of coronary spasm]. / Síncope recurrente sin angina: una presentación infrecuente del espasmo coronario.

We report the case of a 64-year-old patient admitted for repetitive syncope as an isolated clinical manifestation probably due to coronary artery spasm. The patient had no history of previous cardiac disease, and was studied because of two nonspecific syncopes. Long-term electrocardiographic monitoring showed many episodes of transient ST segment elevation, associated with premature ventricular beats and runs of ventricular tachycardia. Coronary angiography during ergonovine infusion was performed to confirm the diagnosis. We discuss the incidence of coronary spasm provoking syncope and the need to establish a correct diagnosis in order to administer an effective therapy to the patient.

[The effectiveness of stents in restinotic lesions and coronary grafts]. / Eficacia del stent en las lesiones reestenóticas e injertos coronarios.

Regarding restenotic lesions, the data suggest that stent implantation decrease the number of cardiac events including the restenosis rate. The higher number of acute cardiac events are related to stent thrombosis, and they are markedly reduced by the new techniques of antiagregation and implantation. The restenosis rate post-stent implantation does not bear relation to the number of previous dilations as it does with conventional angioplasty. Regarding vein grafts, the implantation of different types of stents has a high percentage of success and low rate of acute complications. The longterm survival of these patients is related more to the progression of the coronary arteriosclerosis and tend to worsen with time. Although the data on restenosis are better than with conventional angioplasty, we need to wait for the definitive results after the final conclusions of the randomized trial SAVED.

[Intracoronary stents in small vessels: short- and long-term clinical results]. / Stents intracoronarios en vasos pequeños: resultados clínicos a corto y largo plazo.

OBJECTIVE: To assess the clinical outcome of coronary stenting in small vessels (< 3 mm), using high pressure balloon inflation and antithrombotic therapy. PATIENTS AND METHODS: Vessel size was evaluated as < or >= 3 mm at the time of procedure and measured at a level of maximum diameter. We studied 234 consecutive patients with placement of 300 stents in 279 lesions, comprising 84 stents implanted in 79 lesions located at small vessels (< 3 mm). The standard technique included high pressure balloon inflation (15.8 +/- 2.2 atm) and post-stenting therapy with ticlopidine and aspirin for one month. Mean clinical follow-up was 17.6 +/- 10 months. RESULTS: Procedural success without in-hospital major events was similar between small and large vessels (93.7 in vessels of < 3 mm vs 93.5% in vessels of >= 3 mm; p = NS). Three small vessels presented subacute stent thrombosis, whereas no thrombotic occlusion occurred in large vessels (3.8 vs 0%; p = 0.006). At two years, small vessels had a lower target lesion revascularization free survival (73.6 vs 90.3%; p < 0.001). After adjustment for variables previously described as predictors of stent restenosis, in multivariate analysis, a small vessel of < 3 mm was an independent predictor of target lesion revascularization (p = 0.001). Although patients with stenting in small vessels did not differ significantly in terms of any cause death (4.6 vs 3.8%; p = 0.7) nor acute myocardial infarction (2.9 vs 1.1%; p = 0.3), event-free survival was significantly lower after two years (69.1 vs 86.6%; p < 0.001). CONCLUSIONS: As compared to large vessels, coronary stenting in small vessels was performed with similar rates of initial success, however they had a significantly worse clinical long-term outcome in terms of subacute stent thrombosis and target lesion revascularization at follow-up.

[Hypertrophic myocardiopathy (I). The clinical and echocardiographic characteristics of a population of 72 patients]. / Miocardiopatía hipertrófica (I). Características clínicas y ecocardiográficas en una población de 72 pacientes.

The results of the echocardiographic evaluation of 72 patients with hypertrophic cardiomyopathy are presented. We have measured left ventricular wall thickness in 8 different segments and classified our patients in 6 types according to the hypertrophy extent. Moreover, we have evaluated by Doppler ultrasound the presence and severity of mitral regurgitation and the left ventricular inflow and outflow. The hypertrophy cardiomyopathy pattern was symmetric in 8 patients, apical in five, and asymmetric in 31. According to Maron classification, asymmetric cardiomyopathy was I type: 4 patients, II type: 16, III type: 11, and IV type: 0 patients. There were left ventricular outflow obstruction (greater than 25 mmHg) in 26 patients (36.1%). This obstruction was more frequent in II and III type hypertrophic cardiomyopathy and we found significative relationship between septal posterior segment hypertrophy and left ventricular outflow obstruction. Ventricular inflow showed bad distensibility pattern in 45 patients (62.5%). Mitral regurgitation was mild, moderate and severe in 25, 15, and 4 patients. Left ventricular outflow obstruction, bad distensibility pattern and mitral regurgitation were independent each other.

[Usefulness of transesophageal echocardiography in the diagnosis of coronary anomalies]. / Utilidad de la ecocardiografía transesofágica en el diagnóstico de anomalías coronarias.

BACKGROUND: Although rare, anomalous coronary arteries are associated with myocardial ischemia and sudden death. Identification is made by angiography but its true course is difficult to determine even with this invasive procedure. OBJECTIVES: The purpose of this study is to determine the role of transesophageal echocardiography (TEE), Doppler and color flow Doppler, in identifying the origin and course of anomalous coronary arteries. MATERIAL AND METHODS: Six patients with angiographically confirmed anomalous coronary arteries were studied by TEE, Doppler and color flow Doppler. RESULTS: The abnormal origin was confirmed in all six patients. In three, the left main originated from the right sinus of Valsalva. In one the right coronary artery from the left sinus of Valsalva. One was a single right coronary artery from the right sinus of Valsalva, and one, had a fistula between the coronary artery and the right ventricle. In four, the TEE was able to demonstrate clearly the course in relation to the great vessels, two were interarterial and one posterior. Color flow Doppler was obtained in four patients. In one patient, there was increase in diastolic flow velocity due to proximal coronary obstruction. One had increase of the systolic flow velocity. CONCLUSIONS: TEE is useful test for diagnosing the origin of anomalous coronary arteries and confirming its course in relation to the great vessels. Doppler flow Doppler is useful in localization the vessel.

[The anomalous origin of the left common coronary trunk in the right sinus of Valsalva with an interarterial path. Apropos a case]. / Origen anómalo del tronco coronario común izquierdo en el seno de Valsalva derecho con trayecto interarterial. A propósito de un caso.

We present the case of an old patient with coronary artery disease and two previous myocardial infarctions, admitted to the hospital by syncopal episodes, in which the coronariographic study showed the ectopic origin of the left main coronary artery in the right sinus of Valsalva with anomalous course between the aortic and pulmonary arteries. In this case the initial coronariographic diagnosis and the therapeutical attitude (initially aggressive only in cases of interarterial course) was confirmed by mean of transesophageal echocardiography, showing a better topographical definition of the ectopic vessel aberrant course, although due to the high degree of left ventricular disfunction and the diffuse disease of distal vessels in this patient, CABG surgery was avoided. The angiographic feature is described and the transesophageal approach is remarked as a complementary diagnostic tool in the correct definition of the anomalous course.

[Echocardiography during transesophageal atrial pacing. Its applicability and diagnostic value]. / Ecocardiografía durante la estimulación auricular transesofágica. Aplicabilidad y valor diagnóstico.

INTRODUCTION AND OBJECTIVES: Atrial pacing has been proposed as an alternative method to the isotonic exercise, to induce ischemia, and, joined to two-dimensional echocardiography, as one of the main modalities in stress echo. In order to analyse its applicability and diagnostic value in assessing coronary artery disease this study was undertaken. PATIENTS AND METHODS: 52 patients referred to coronarography for suspicion or evaluation of ischemic disease, were submitted to this technique. RESULTS: The study was completed in 44 patients (applicability rate of 84,7%). The results obtained showed a sensitivity, specificity and diagnostic accuracy for the regional wall motion abnormalities echocardiographically detected, of 88%, 68% and 79%, respectively. When electrocardiographic changes or presence of angina during atrial pacing were added to echocardiographic data, sensitivity increased to 96%. In 41 patients in which a conventional stress test was available, sensitivity was 55% electrocardiographically, 33% clinically and 68% globally. CONCLUSIONS: It is concluded that transthoracic two-dimensional echocardiography during atrial pacing is a safe, highly sensitive method for coronary artery disease detection. The limitations of the method for its routine clinical application are also analysed.

[Malignant vasovagal syncope: its diagnosis and therapeutic trial based on the orthostatism test (the tilt-table test)]. / Síncope vasovagal maligno: diagnóstico y ensayo terapéutico basado en el test de ortostatismo (test de TILT).

Seventy consecutive patients with recurrent unexplained syncope were evaluated by use of an up-right tilt-table test for 45 minutes (with or without an infusion of isoproterenol) in an attempt to reproduce symptoms. There were 42 males and 28 females with a mean age of 49 +/- 20 years (range 7-86), and with a mean symptoms duration of 35.2 +/- 16 months. All the patients underwent clinical examination which includes cardiological and neurological evaluation. Some tilt positive patients received therapy with either transdermal scopolamine, metoprolol or clonidine, the efficacy of which was evaluated by another tilt-table test. Syncope occurred in sixteen patients (22.9%), during the baseline tilt associated with hypotension (2 patients), bradycardia-asystolia (3 patients), or both (11 patients). In 11 patients with normal baseline tilt test, isoproterenol infusion was used appearing 4 new cases of abnormal response. Some patients who had positive test results, eventually became tilt-table negative by therapy (5 out of 8 patients treated with scopolamine, 5 out of 6 patients with metoprolol, and 3 out of 5 patients with clonidine). Time before syncope during tilt-test was increased with therapy, being of 45 min in normalized cases, and increasing from 11.9 +/- 16 basal to 34.4 +/- 17 min with scopolamine (p < 0.05), to 40 +/- 12 min with metoprolol (p < 0.05) and to 33.7 +/- 16.7 min with clonidine (p = NS). We conclude that upright tilt-table alone or combined with isoproterenol infusion is an useful test in the diagnosis of vasovagal syncope and in the evaluation of therapy.

[Complications at the first month following various types of intracoronary stents, implanted with high pressure without intracoronary ultrasonography or anticoagulation]. / Complicaciones en el primer mes de varios tipos de stents intracoronarios, implantados a altas presiones sin ayuda de ultrasonidos intracoronarios ni anticoagulación.

BACKGROUND: Coronary stents have proved their efficacy in bail-out situations and restenosis. Nevertheless, the high incidence of subacute thrombosis and vascular and bleeding complications limits its use. OBJECTIVES: To evaluate the clinical complications during the first month of three different types of stents, implanted with high pressure, without ultrasound guidance or anticoagulation. PATIENTS AND METHODS: All stents were implanted in arteries of 3 mm or more. After implantation, all stents were dilated between 15-17 atmospheres, aiming to a residual stenosis lower than 10%. After implantation, all patients received aspirin indefinitely and ticlopidine 250 mg twice daily for one month. The initial success, the ischemic complications (death, myocardial infarction and emergency surgery), acute and subacute thrombosis and vascular and hemorrhagic complications were evaluated. The evaluation was done following the procedure, prior to discharge from the hospital and at 1 month follow-up. RESULTS: In 49 patients, 51 stents were implanted. 70% had unstable angina. In one case the stent was implanted after primary PTCA. In 17.6%, the stent was implanted in a bail-out situation. Of the 51 stents, 32 were Palmaz-Schatz, 12 Wiktor and 7 Gianturco-Roubin. The initial success was 100%. There were no deaths, AMI, nor emergency surgeries in the first month. There was no case of acute or subacute thrombosis. There were 2 minor complications; one vascular: a pseudoaneurysm, and another hemorrhagic: an inguinal hematoma. Neither case needed surgery nor blood transfusion. All patients were discharged within 48 hours. CONCLUSION: Implantation of stents with high pressures, in spite of not using guidance ultrasound nor anticoagulation, is safe and effective, with a clear decrease in vascular complications, and without an increase in the incidence of acute or subacute thrombosis.

[Is the predischarge exercise test valid in patients younger than 40 years old after myocardial infarct for determination of multivascular disease?]. / Es válida la prueba de esfuerzo precoz en pacientes jóvenes menores de 40 años tras infarto de miocardio para la determinación de enfermedad multivaso?

BACKGROUND AND OBJECTIVES: Conventional exercise testing before hospital discharge is the most useful procedure in order to estimate postinfarction prognosis and in detecting multivessel coronary disease which is associated with a poor long-term prognosis. There are no bibliographic reports about it in younger myocardial infarction survivors. The aim of the study was to evaluate sensitivity, specificity and predictive value of symptoms limited maximal exercise testing for multivessel disease diagnosis in young patients after myocardial infarction. METHODS: Myocardial infarction survivors until the age of 40 performed symptoms limited maximal exercise testing and had a coronary arteriography before hospital discharge. RESULTS: A total of 100 consecutive patients were included, although in only 83 of them exercise tests and coronariographic studies were done. In this group, multivessel disease was confirmed in 27 patients (15 with positive tests and 12 with normal exercise testing). In the remaining 56 young adults without multivessel involvement, positive tests were only observed in 15 patients and normal tests in 45. Thus, a sensitivity of 56%, specificity of 73%, positive predictive value of 50% and negative predictive value of 77% were found. When patients showed high risk exercise test criteria, the exercise test positive predictive value increased to 80%. CONCLUSIONS: Due to the lower sensitivity of this test in young myocardial infarction survivors for detecting multivessel artery disease, we remark on the need for predischarge complementary tests such as isotopic, stress echocardiography or coronariography testing.

[Use of screening mammography and its demographic and risk determinants in women 25 to 65 years of age]. / Utilización de la mamografía de cribado y sus determinantes demográficos y de riesgo entre mujeres de 25 a 65 años.

BACKGROUND: To know the utilization of the screening mammography among women from 25 to 65 years old in an urban health zone, where there is not an specific screening program for breast cancer. To detect the demographic and risk determinants that are involved in the mammography screening use. SUBJECTS AND METHODS: A sample of 1,240 women were interviewed consecutively as they visited their physician. Risk factors, sociodemographic variables and use of health services were analyzed. The associated variables with the use of mammography screening were determined by univariant analysis. A multiple logistic regression model was designed to identify the variables independently associated with the use of mammography screening. RESULTS: The percentage of interviewed women who have completed at least one mammography screening in the last three years has been 10.2 +/- 3% (confidence level: 95%), 68.3% of them were under 50 years old. The variables independently associated with the use of mammography screening were: age (OR = 1.08); routine visit to the gynecologist (OR = 8.13); educational level (primary: OR = 2.44, secondary: OR = 3.66, university: OR = 7.43, no schooling: reference level); and knowledge about the benefits of mammography screening (OR = 6.15). Family history of breast cancer and the other risk factors were found not to be associated with the use of mammography screening. CONCLUSIONS: The use of mammography screening among women from 25 to 65 years is inadequate according to the age and other risk factors. Mammography screening among women with a family history of breast cancer and those over 50 years old is underused, so it would be recommended and their use increased for these women. But women under 40 years old without family history of breast cancer have to be dissuaded from undertaking such a screening.

[Morgagni hernia in childhood]. / Hernias de Morgagni en la infancia.

We report six cases of Morgagni hernia diagnosed and operated on in our pediatric surgical unit during a 14-year period. Four children were younger than 1 year and two between 1 and 2 years. Predominance in males was found. Associated congenital pathology was present in 3 children (Down's syndrome, diaphragmatic relaxation, criptorquidia and pyelo-ureteral stenosis). Predominant clinical features were respiratory infections and vomiting. In only one patient clinical onset was with respiratory distress. Plain chest x-ray was the most used diagnostic procedure. In all cases barium enema was performed to confirm the clinical diagnosis. Most frequent surgical approach was a midline supra-umbilical laparotomy. Diaphragmatic defect was left sided in 3 children and right-sided in the other 3. Transverse colon and liver were the most frequent herniated viscera. Postoperative follow-up showed no complications or recidives.

Eye-hand and eye-foot visual reaction times of young soccer players.

PURPOSE: The aim of this study was to investigate the eye-hand and eye-foot visual reaction time among young soccer players and to compare those with non-soccer players in order to evaluate possible differences. METHODS: A vision screening of 53 young male soccer players belonging to the Valencia Soccer Club was done. Soccer players were divided in three categories, with mean ages of 8.2 +/- 0.5 years (range, 8- to 9-year olds), 10.6 +/- 0.2 years (range, 10- to 11-year-olds), and 12.7 +/- 0.3 years (range, 12- to 13-year-olds). An age-matched sample of 60 young male non-soccer players served as a control population. Mean ages in this population were 8.3 +/- 0.6 years, 10.5 +/- 0.4 years, and 12.6 +/- 0.2 years for each category, respectively. Eye-hand and eye-foot visual reaction times were determined in players and non-players by means of a computer-controlled stimuli device. RESULTS: We obtained a mean and standard deviation value (in seconds) of eye-hand reaction time in soccer players of 0.301 +/- 0.037, 0.256 +/- 0.040, and 0.207 +/- 0.031, respectively, for each category, and for non-soccer players of 0.382 +/- 0.061, 0.320 +/- 0.063, and 0.282 +/- 0.043, respectively. The values for eye-foot reaction time in players were: 0.412 +/- 0.062, 0.406 +/- 0.046, and 0.387 +/- 0.034, respectively, for each category, and for nonplayers of 0.496 +/- 0.081, 0.460 +/- 0.026, and 0.446 +/- 0.054, respectively. There are statistically significant differences between eye-hand and eye-foot reaction times between players and nonplayers (p < 0.05). There was no correlation between visual reaction times and age (p > 0.05). CONCLUSIONS: Eye-hand and eye-foot visual reaction times were found to be different between the two populations evaluated. The results show differences between soccer and non-soccer players, with the soccer players demonstrating faster reaction times.

[An agenda to debate: the World Bank report Investing in Health]. / Una agenda a debate: el informe del Banco Mundial "Invertir en salud".

The 1993 World Bank Development Report analyzes the world health situation from an economic perspective. In spite of the fact that many of the discussed topics are controversial, the report accomplishes an interesting review of different health and socioeconomic indicators. The experts of WHO and the World Bank elaborated a new measurement of the global burden of disease, the Disability-Adjusted Life Years (DALYs). It's an indicator that summarizes the health status of a population, combining mortality, morbidity and disability data. We think that the development of this new indicator is the most novel and positive aspect of the report. This indicator stimulates comparisons between countries and facilitates decision making processes in the health field. The present work summarizes and analyses the most interesting and controversial aspects of the World Bank Development Report.

[Duodenal atresia and heterotaxia]. / Atresia duodenal y heterotaxia.

We report two cases of duodenal atresia associated with corporal symmetry changes. The one of them presented a "situs inversus total" and the other one a Ivermak syndrome. The association between duodenal atresia and Ivermak syndrome has a very low incidence. We have not found references with respect to the association between duodenal atresia and "situs inversus totalis". The embryo-genetic hypothesis that could relate both anomalies are discussed. Perhaps are not caused by chance.

[Intraoperative awakening: report of a case in pediatric surgery]. / Despertar intraoperatorio: presentación de un caso en cirugía pediátrica.

Intraoperatory awakening or awareness can be defined as recovering of conscience during general anesthesia. We report such a case happened in a 11 year-old boy during a hypospadias repair. After anesthetic education he related intraoperatory conscience without pain, anxiety, displeasing symptoms or long-term psychoconductal distress. We remark fisiopathology, diagnostic and preventive aspects of this rare event in pediatric surgery.