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Pulmonary tuberculosis is a common infection associated with immunocompromised state. It usually presents with fibrosis or fibrocavitary lesions in the lung. We report a case of bilateral tuberculous pneumonia of acute presentation in a young lady who was being treated for systemic lupus erythematosus.
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AIMS: The Sideguard® stent (Cappella Medical Devices Ltd, Galway, Ireland), is a novel nitinol self-expanding dedicated bifurcation stent that flares proximally at the ostium of the side branch (SB) into a trumpet shape thereby achieving full ostial coverage. The aim of this study is to report the utility and limitations of this stent in patients undergoing treatment to bifurcation coronary lesions in a real-world setting. METHODS AND RESULTS: We prospectively identified 20 successive patients admitted over a 6-month period in whom there was significant SB disease and who were suitable for a bifurcation procedure. The Sideguard® stent was successfully used in all 20 cases including several that would have been technically difficult using conventional bifurcation techniques. We highlight use of this system using five illustrative cases that illustrate its utility and limitations in the treatment of bifurcation lesions. CONCLUSIONS: The Sideguard® stent can be used to treat complex bifurcation lesions in a straight forward manner and is not subject to the limitations associated with conventional bifurcation PCI techniques including jailing of the SB ostium and inability to fully cover/scaffold the ostium of the SB.
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Síndrome Coronariana Aguda/terapia , Angioplastia Coronária com Balão/instrumentação , Angioplastia Coronária com Balão/métodos , Estenose Coronária/terapia , Anomalias dos Vasos Coronários/terapia , Stents/classificação , Adulto , Idoso , Angiografia Coronária , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIMS: Prompt coronary reperfusion following acute ST-segment elevation myocardial infarction is pivotal to survival. Primary angioplasty is the gold standard in restoring reperfusion, but thrombolysis needs consideration when optimal call to balloon time is not feasible. Following lysis and with evolving pharmacoinvasive therapies, the advantage of routine, early percutaneous coronary intervention (PCI) over standard ischaemia-guided PCI remains debatable. We meta-analysed studies comparing these two interventional strategies. METHODS AND RESULTS: A MEDLINE search for randomized control studies was performed using the search terms 'coronary, thrombolysis, early or immediate stenting, and acute ST-elevation myocardial infarction'. Further, relevant studies were identified from global cardiovascular scientific sessions/congresses. Two interventional strategies were studied in 3195 patients in eight trials and meta-analysed using a random effects model. The combined endpoint of 30-day mortality, re-infarction, and ischaemia was reached in 106/1487 (7.3%) patients in the routine early PCI group and in 199/1470 (13.5%) patients in the ischaemia-guided PCI group following lysis with odds ratio (OR) 0.47 [95% confidence interval (CI), 0.32-0.68, P < 0.0001] favouring routine early PCI, driven by significant reduction in both re-infarction OR 0.62 (95% CI, 0.42-0.90, P < 0.011) and ischaemia OR 0.21 (95% CI, 0.10-0.47, P < 0.001). Thirty-day mortality or major bleeding rates between strategies were not significantly different. CONCLUSION: Where primary PCI is not feasible, our meta-analysis favours routine early PCI within 24 h of thrombolysis for acute ST-elevation myocardial infarction-a strategy that is safe and a time-target that is easily achievable. Early PCI is associated with reduced recurrence of ischaemia and re-infarction, but at no increased risk of major haemorrhage.
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Angioplastia Coronária com Balão/métodos , Infarto do Miocárdio/terapia , Reperfusão Miocárdica/métodos , Viés , Angiografia Coronária/métodos , Hemorragia/etiologia , Humanos , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Prevenção Secundária , Terapia Trombolítica/métodos , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: Little is known about the effect of chronic beta-blockade on adenosine actions. We sought to investigate the effect of oral beta-blockers on the presence, extent, and severity of myocardial perfusion abnormality induced by adenosine in patients with coronary artery disease. METHODS: In this crossover study, 45 male patients with coronary artery disease on beta-blocker therapy with atenolol, bisoprolol, or metoprolol underwent adenosine myocardial perfusion imaging both on and off beta-blockade in a random order on separate days. Myocardial perfusion was assessed both qualitatively and quantitatively. Hemodynamic response, image analysis, and sensitivity for the detection of coronary stenosis (>or=50% luminal diameter reduction on x-ray coronary angiography) were compared between the on and off beta-blocker studies. RESULTS: Rate pressure product both at baseline and at peak adenosine infusion decreased by 23% +/- 15% and 21% +/- 18%, respectively, after beta-blockade (P < 0.001 for all). The median (interquartile range) summed difference score, a measure of defect reversibility, and quantitative defect size were both significantly lower after beta-blockade (median, 7.0 [interquartile range, 2.0-9.5] vs. median, 5.0 [interquartile range, 0-8.0], P = 0.002; and quantitative defect size, 18% [interquartile range, 9%-34%] vs. quantitative defect size, 6% [interquartile range, 0%-19%], P < 0.001, respectively). The overall sensitivity for the detection of coronary stenosis decreased from 0.76 (95% confidence interval, 0.65-0.88) to 0.58 (95% confidence interval, 0.45-0.71) after beta-blockade (P = 0.03). CONCLUSION: beta-blockade causes a small but significant reduction in the extent and severity of perfusion abnormality by adenosine. This may reduce the diagnostic sensitivity of adenosine myocardial perfusion imaging for the detection of flow-limiting coronary stenosis.
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Adenosina/efeitos adversos , Adenosina/antagonistas & inibidores , Antagonistas Adrenérgicos beta/uso terapêutico , Atenolol/uso terapêutico , Circulação Coronária/efeitos dos fármacos , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/tratamento farmacológico , Coração/diagnóstico por imagem , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/tratamento farmacológico , Vasodilatadores/efeitos adversos , Vasodilatadores/antagonistas & inibidores , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Atenolol/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estudos Cross-Over , Eletrocardiografia/efeitos dos fármacos , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Compostos Organofosforados , Compostos de Organotecnécio , Tomografia Computadorizada de Emissão de Fóton ÚnicoRESUMO
OBJECTIVE: The aim of this study is to investigate the feasibility of using a 6.5 Fr sheathless guide catheter as a default system in transradial (TRA) percutaneous coronary intervention (PCI). BACKGROUND: TRA PCI has been shown to reduce mortality rates through a reduction in access site related bleeding complications compared with procedures performed though a femoral approach. Complications associated with the TRA route increase with the size of sheath used. These complications may be reduced by the use of a sheathless guide catheter system (Asahi Intecc, Japan) that is 1-2 Fr sizes smaller in diameter than the corresponding introducer sheath. METHODS: We performed PCI in 100 consecutive cases using 6.5 Fr sheathless guides to determine the procedural success, rates of symptomatic radial spasm and radial occlusion. RESULTS: Procedural success using the 6.5 Fr sheathless guide catheter system was 100% with no cases requiring conversion to a conventional guide and catheter system. There were no procedural complications recorded associated with the use of the catheter. Adjunctive devices used in this cohort included IVUS, stent delivery catheters, distal protection devices, and simple thrombectomy catheters. The rate of radial spasm was 5% and the rate of radial occlusion at 2 months was 2%. CONCLUSION: Use of the 6.5 Fr sheathless guide catheter system, which has an outer diameter <5 Fr sheath, as the default system in routine PCI is feasible with a high rate of procedural success via the radial artery.
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Angioplastia Coronária com Balão/instrumentação , Doença da Artéria Coronariana/terapia , Artéria Radial , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/métodos , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/etiologia , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Punções , Espasmo/diagnóstico por imagem , Espasmo/etiologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia DopplerRESUMO
Drug-eluting stents (DES) have made a tremendous impact on the practice of percutaneous coronary intervention. Recently however, long-term DES failures have become a focal point, particularly with restenosis and thrombosis. An uncommon, yet important cause of DES failure is stent fracture. Of the two established first generation DES, the sirolimus-eluting stent (SES) has been particularly linked to cases of stent fracture, likely as a result of its closed cell design compared with other DES employing an open cell system. We present 2 cases of SES fracture confirmed using high-resolution intravascular optical coherence tomography giving unique insights into the in-vivo appearance of this complication.
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Reestenose Coronária/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Stents Farmacológicos/efeitos adversos , Sirolimo/administração & dosagem , Tomografia de Coerência Óptica/métodos , Idoso , Reestenose Coronária/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Falha de Prótese , Tomografia de Coerência Óptica/estatística & dados numéricos , UltrassonografiaRESUMO
BACKGROUND AND OBJECTIVES: Interleukin (IL)-23 is a key regulator of inflammation and influences the activities of T-helper 17 (Th-17) lymphocytes. Recent reports indicate that variants in the gene coding for its receptor (IL-23R) are strongly associated with Crohn's disease (CD). We investigated whether DNA variants in the IL-23R gene determine susceptibility for CD in Canadian children. DESIGN AND METHODS: A case-control and case-parent trio design was implemented at three pediatric centers across Canada. Cases of CD (=20 yr) along with their parents and controls were recruited. DNA samples were collected and genotyped for 10 single nucleotide polymorphisms (SNPs) in the IL-23R gene and three common SNPs in the CARD15 gene. Transmission disequilibrium-based tests were applied to the case-parent data and logistic regression models to the case-control data to study the association between the SNPs and CD. RESULTS: A total of 259 CD cases, 139 controls, and 232 families (167 trios and 65 dyads) were studied. The mean age at diagnosis was 13.3 yr (range 2.6-20 yr). The majority of the patients were Caucasian. Case-control analysis revealed significant associations with three SNPs (rs1004819, rs7517847, and rs11209026 [R381Q]) and borderline nonsignificant associations with three other SNPs (rs10489629, rs10889697, and rs11465804) in the IL-23R gene. Having any CARD15 variant was associated with a significant risk for CD (P < 0.0001). Analyses of case-parent data confirmed the findings from the case-control analysis including significant associations with the R381Q SNP (P= 0.002). The common variant in this SNP conferred risk for CD. These associations were largely independent of the CARD15 gene. CONCLUSIONS: Our findings confirm recently reported genome-wide associations between the IL-23R gene and CD. They suggest that the gene is also associated with pediatric-onset CD among Canadian children.
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Doença de Crohn/genética , Predisposição Genética para Doença , Polimorfismo de Nucleotídeo Único , Receptores de Interleucina/genética , Adolescente , Adulto , Idade de Início , Canadá , Estudos de Casos e Controles , Criança , Pré-Escolar , Humanos , Proteína Adaptadora de Sinalização NOD2/genéticaRESUMO
BACKGROUND: Some dietary foods are considered protective (vegetables and fruits), whereas others (fatty foods) are thought to enhance the risk for Crohn's disease (CD). The evidence, however, is inconsistent. METHODS: We postulated that specific dietary patterns may influence the risk for CD. A case-control study was carried out. Newly diagnosed CD cases with population and/or hospital-based controls < or =20 years were selected from 3 tertiary hospitals across Canada. Pre-disease diet was assessed using a validated food frequency questionnaire (FFQ) administered within 1 month of diagnosis. Factor analyses and unconditional logistic regression (adjusted) was used to determine gender-specific dietary patterns and assess associated risks for CD. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were estimated. RESULTS: A total of 149 cases and 251 controls were included. The mean age (range) of the cases was 13.3 (2.6-20 years). There were more boys (61.1%). Four dietary patterns each were observed among both boys and girls. Pattern 1 in girls, characterized by meats, fatty foods, and desserts, was positively associated with CD (OR 4.7, 95% CI 1.6-14.2). Pattern 2, common to both boys and girls, was characterized by vegetables, fruits, olive oil, fish, grains, and nuts and was inversely associated with CD in both genders (girls: OR 0.3, 95% CI 0.1-0.9; boys: OR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in children. Larger prospective studies are required to confirm these findings.
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Doença de Crohn/epidemiologia , Doença de Crohn/etiologia , Dieta , Adolescente , Adulto , Distribuição por Idade , Canadá/epidemiologia , Criança , Intervalos de Confiança , Feminino , Seguimentos , Humanos , Incidência , Masculino , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Fatores de TempoRESUMO
BACKGROUND AND OBJECTIVES: The role of dietary factors in the etiology of Crohn's disease (CD) is inconsistent largely due to difficulties in acquiring valid information on consumption habits. We examined the impact of diet on new onset CD in children using a validated food-frequency questionnaire (FFQ). METHODOLOGY: A case-control study was carried out. Children < or =20 yr, newly diagnosed with CD, were recruited from 3 pediatric gastroenterology clinics across Canada. Population or hospital controls were selected matched to cases for time of diagnosis (+/-6 months) and area of residence. Dietary consumption 1 yr prior to disease diagnosis was evaluated using a validated FFQ, administered within 1 month of diagnosis. Conditional logistic regression analysis adjusting for potential confounding variables (energy intake, age, gender, body mass index) was carried out. RESULTS: A total of 130 CD patients and 202 controls were studied. Mean age at diagnosis (+/-SD) was 14.2 (2.7). There were more male patients (59%). Comparing the highest to the lowest levels of consumption, higher amounts of vegetables (OR 0.69, 95% CI 0.33-1.44, P= 0.03), fruits (OR 0.49, 95% CI 0.25-0.96, P= 0.02), fish (OR 0.46, 95% CI 0.20-1.06, P= 0.02), and dietary fiber (OR 0.12, 95% CI 0.04-0.37, P < 0.001) protected from CD. Consumption of long-chain omega-3 fatty acids (LCN-omega-3) was negatively associated with CD (OR 0.44, 95% CI 0.19-1.00, P < 0.001). A higher ratio of LCN-omega-3/omega-6 fatty acids was significantly associated with lower risks for CD (OR 0.32, 95% CI 0.14-0.71, P= 0.02). CONCLUSIONS: Our findings indicate that an imbalance in consumption of fatty acids, vegetables, and fruits is associated with increased risks for CD among Canadian children.
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Doença de Crohn/etiologia , Dieta/efeitos adversos , Adolescente , Criança , Doença de Crohn/prevenção & controle , Gorduras na Dieta/administração & dosagem , Ácidos Graxos/administração & dosagem , Feminino , Frutas , Humanos , Masculino , Fatores de Risco , Inquéritos e Questionários , VerdurasRESUMO
The natriuretic peptides, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and C-type natriuretic peptide (CNP), are a family of polypeptide mediators exerting numerous actions in cardiovascular homeostasis. ANP and BNP are cardiac derived, being secreted and up-regulated in myocardium in response to many pathophysiological stimuli. CNP is an endothelium-derived mediator. The classical endocrine effects of ANP and BNP on fluid homeostasis and blood pressure, especially in conditions characterised by left ventricular dysfunction, are well recognised and extensively researched. However, there is accumulating evidence that, in addition to endocrine actions, ANP and BNP exhibit important autocrine and paracrine functions within the heart and coronary circulation. These include regulation of myocyte growth, inhibition of fibroblast proliferation and extracellular matrix deposition, a cytoprotective anti-ischaemic (preconditioning-like) function, and influences on coronary endothelium and vascular smooth muscle proliferation and contractility. Most if not all of these actions can be ascribed to particulate guanylyl cyclase activation because the ANP/BNP receptor, natriuretic peptide receptor (NPR)-A, has an intracellular guanylyl cyclase domain. Subsequent elevation of the intracellular second messenger cGMP may exert diverse physiological effects through activation of cGMP-dependent protein kinases (cGK), predominantly cGK-I. However, there appear to be other contributory mechanisms in several of these actions, including the augmentation of nitric oxide synthesis. These diverse actions may represent counterregulatory mechanisms in the pathophysiology of many cardiovascular diseases, not just those typified by left ventricular dysfunction. Ultimately, insights from the autocrine/paracrine actions of natriuretic peptides may provide routes to therapeutic application in cardiac diseases of natriuretic peptides and drugs that modify their availability.
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Comunicação Autócrina/fisiologia , Coração/fisiologia , Peptídeos Natriuréticos/fisiologia , Comunicação Parácrina/fisiologia , Animais , Guanilato Ciclase/fisiologia , Contração Miocárdica/fisiologia , Isquemia Miocárdica/metabolismo , Isquemia Miocárdica/fisiopatologia , Receptores do Fator Natriurético Atrial/fisiologia , Transdução de Sinais/fisiologia , Vasodilatação/fisiologiaRESUMO
B-type natriuretic peptide (BNP) has been reported to be released from the myocardium during ischemia. We hypothesized that BNP mediates cardioprotection during ischemia-reperfusion and examined whether exogenous BNP limits myocardial infarction and the potential role of ATP-sensitive potassium (K(ATP)) channel opening. Langendorff-perfused rat hearts underwent 35 min of left coronary artery occlusion and 120 min of reperfusion. The control infarct-to-risk ratio was 44.8 +/- 4.4% (means +/- SE). BNP perfused 10 min before ischemia limited infarct size in a concentration-dependent manner, with maximal protection observed at 10(-8) M (infarct-to-risk ratio: 20.1 +/- 5.2%, P < 0.01 vs. control), associated with a 2.5-fold elevation of myocardial cGMP above the control value. To examine the role of K(ATP) channel opening, glibenclamide (10(-6) M), 5-hydroxydecanoate (5-HD; 10(-4) M), or HMR-1098 (10(-5) M) was coperfused with BNP (10(-8) M). Protection afforded by BNP was abolished by glibenclamide or 5-HD but not by HMR-1098, suggesting the involvement of putative mitochondrial but not sarcolemmal K(ATP) channel opening. We conclude that natriuretic peptide/cGMP/K(ATP) channel signaling may constitute an important injury-limiting mechanism in myocardium.