Multidisciplinary Management of Suspected Lyme Borreliosis: Clinical Features of 569 Patients, and Factors Associated with Recovery at 3 and 12 Months, a Prospective Cohort Study.

Introduction. Because patients with a suspicion of Lyme borreliosis (LB) may have experienced difficult care paths, the Tick-Borne Diseases Reference Center (TBD-RC) was started in 2017. The aim of our study was to compare the clinical features of patients according to their final diagnoses, and to determine the factors associated with recovery in the context of multidisciplinary management for suspected LB. Methods. We included all adult patients who were seen at the TBD-RC (2017-2020). Four groups were defined: (i) confirmed LB, (ii) possible LB, (iii) Post-Treatment Lyme Disease Syndrome (PTLDS) or sequelae, and (iv) other diagnoses. Their clinical evolution at 3, 6, and 9-12 months after care was compared. Factors associated with recovery at 3 and at 9-12 months were identified using logistic regression models. Results. Among the 569 patients who consulted, 72 (12.6%) had confirmed LB, 43 (7.6%) possible LB, 58 (10.2%) PTLDS/sequelae, and 396 (69.2%) another diagnosis. A favorable evolution was observed in 389/569 (68.4%) at three months and in 459/569 (80.7%) at 12 months, independent of the final diagnosis. A longer delay between the first symptoms and the first consultation at the TBD-RC (p = 0.001), the multiplicity of the diagnoses (p = 0.004), and the inappropriate prescription of long-term antibiotic therapy (p = 0.023) were negatively associated with recovery, reflecting serial misdiagnoses. Conclusions. A multidisciplinary team dedicated to suspicion of LB may achieve a more precise diagnosis and better patient-centered medical support in the adapted clinical sector with a shorter delay, enabling clinical improvement and avoiding inappropriate antimicrobial prescription.

Ivermectin to prevent hospitalizations in patients with COVID-19 (IVERCOR-COVID19): a structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: To assess the efficacy of ivermectin in addition to standard treatment compared to standard treatment alone in reducing hospitalizations in the COVID-19 patient population. TRIAL DESIGN: IVERCOR-COVID19 will be a single-center, prospective, randomized, double-blind, parallel group (1:1 ratio), placebo-controlled study. PARTICIPANTS: Patients who meet the following criteria will be invited to participate: Inclusion criteria: (1) Over 18 years of age who reside in the province of Corrientes at the time of diagnosis. (2) Confirmed diagnosis of COVID-19 by polymerase chain reaction (PCR) test for detection of SARS-CoV2 in the last 48 h. (3) In the case of women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study and for the entire period of time for the duration of the study and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study). (4) Weight at the time of inclusion greater than 48 kg. (5) That they sign the informed consent for participation in the study. EXCLUSION CRITERIA: (1) pregnant or breastfeeding women; (2) known allergy to ivermectin or some of the components of ivermectin tablets or placebo; (3) current use of home oxygen; (4) require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19; (5) presence of mal-absorptive syndrome; (6) presence of any other concomitant acute infectious disease; (7) known history of severe liver disease, for example liver cirrhosis; (8) need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19; (9) need or use of hydroxychloroquine or chloroquine; (10) use of ivermectin up to 7 days prior to randomization; (11) patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months; and (12) current participation or in the last 30 days in a research study that has included the administration of a drug (Table 1). Table 1 Ivermectin/placebo dose according to patient weight Patient weight Ivermectin/placebo dose Total dose (mg) Equal to or greater than 48 kg and less than 80 kg 2 tablets of 6 mg each at the time of inclusion and 2 tablets 24 h after the first intake 24 Equal or greater than 80 kg and less than 110 kg 3 tablets of 6 mg each at the time of inclusion and 3 tablets 24 h after the first intake 36 Equal or greater than 110 kg 4 tablets of 6 mg each at the time of inclusion and 4 tablets 24 h after the first intake 48 The study will be carried out by the Ministry of Public Health of the Province of Corrientes (Argentina) in coordination with the Institute of Cardiology of Corrientes in the Province of Corrientes, Argentina. INTERVENTION AND COMPARATOR: Intervention group: patients who are randomized to ivermectin will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg ivermectin; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of ivermectin; patients weighing more than 110 kg will receive 4 tablets of 6 mg ivermectin) the day they enter the study and the same dose 24 h after the first dose. CONTROL GROUP: patients who are randomized to placebo will receive the dose according to their weight (patients up to 80 kg will receive 2 tablets of 6 mg placebo; patients with more than 80 kg and up to 110 kg will receive 3 tablets of 6 mg of placebo; patients weighing more than 110 kg will receive 4 tablets of 6 mg placebo) on the day they enter the study and the same dose 24 h after the first dose (Table 2). Table 2 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria 1. Over 18 years of age who reside in the province of Corrientes at the time of diagnosis 1. Pregnant or breastfeeding women 2.Confirmed diagnosis of COVID-19 by polymerase chain reaction test for detection of SARS-CoV2 in the last 48 h 2. Known allergy to ivermectin or some of the components of ivermectin tablets or placebo 3. In case of being women of childbearing age, they must be using a contraceptive method of proven efficacy and safety (barrier, hormonal, or permanent contraceptives) for at least 3 months prior to inclusion in the present study, during the entire period of time for the duration of the study, and until at least 30 days after the end of this study. A woman will be considered to have no reproductive capacity if she is postmenopausal (at least 2 years without her menstrual cycles) or if she has undergone surgical sterilization (at least 1 month before the time of inviting her to participate in this study) 3. Current use of home oxygen 4. Weight at the time of inclusion equal to or greater than 48 kg 4. That require hospitalization due to COVID-19 at the time of diagnosis or history of hospitalization for COVID-19 5. That they sign the informed consent for participation in the study 5. Presence of mal-absorptive syndrome 6. Presence of any other concomitant acute infectious disease 7. Known history of severe liver disease, for example liver cirrhosis 8. Need or use of antiviral drugs at the time of admission for another viral pathology other than COVID-19 9. Need or use of hydroxychloroquine or chloroquine 10. Use of ivermectin up to 7 days prior to randomization 11. Patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months 12. Current participation or in the last 30 days in a research study that has included the administration of a drug MAIN OUTCOMES: Primary outcome will be the percentage of hospitalizations in patients with COVID-19 in the intervention and control groups. SECONDARY OUTCOMES: time to hospitalization in each of the arms of the study: number of days elapsed from the inclusion in the study until the hospitalization of the patient; percentage of use of invasive mechanical ventilation in each of the study arms: every patient who is connected to invasive mechanical ventilation after signing the informed consent and before the final study visit; time to invasive mechanical ventilation in each of the arms of the study: number of days elapsed from inclusion in the study to connection to invasive mechanical ventilation of the patient; percentage of patients requiring dialysis in each of the study arms: all patients who require renal replacement therapy of any kind, temporary or permanent, and which begins after signing the informed consent and before the final visit; mortality from all causes in each of the two trial groups: death of the patient, from any cause. Negative PCR swab at 3 ± 1 and 12 ± 2 days after entering the study. Ivermectin safety: it will be analyzed according to the incidence of adverse events that patients present in the intervention and control groups. The end of study (EOS) is recorded as the day the patient is discharged or death. Discharge will be granted according to the current recommendations of the Ministry of Public Health of the Province of Corrientes. A follow-up visit (EOF) will be made by phone 30 days after the EOS when vital status will be verified. RANDOMIZATION: Randomization will be done through a web system with randomly permuted blocks. Randomization will be carried out by one of the investigators who will not participate in the inclusion of patients or in the delivery of medication (Table 3). Table 3 EOS end of study, EOF end of follow-up Visit Basal and randomization, day 0 Day 3 ± 1 Day 12 ± 2 V#1 V#2 V#3 EOS EOF Informed consent X - - - - Inclusion/exclusion criteria X - - - - Demographic data and medical history X - - - - Concomitant medication X - - - - Vital signs* X X - - - Anthropometric data^ X - - - - Basal laboratory X - - - - PCR swab - X X - - Assessment of adverse events - X X X - Final objective evaluation - X X X X Randomization X - - - - Adherence to treatment X X - - - *Includes heart rate, temperature, and oxygen saturation by a digital saturometer ^Includes weight and height BLINDING (MASKING): The participants, investigators, care providers, and outcome assessors will be blinded. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): We will include a total of 500 patients (250 patients in each group). TRIAL STATUS: This is version 1.0, 17 August 2020. The recruitment started on 19 August 2020, and we anticipate the trial will finish recruitment on 31 December 2020. TRIAL REGISTRATION: ClinicalTrials.gov NCT04529525 . Registered on 26 August 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting the dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

[Argentine Consensus in effective management of anticoagulation clinics for the use of vitamin k antagonists]. / Consenso Argentino en gestión efectiva de clínicas de anticoagulación para el uso de antagonistas de la vitamina k.

Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.

El tratamiento de un paciente anticoagulado con antagonistas de la vitamina K (AVK) sigue siendo un desafío, especialmente en regiones donde, por el costo, los dicumarínicos son todavía la alternativa más buscada a la hora de elegir un anticoagulante oral. Las clínicas de anticoagulación han demostrado ser la forma más eficiente y segura de evitar complicaciones trombóticas y hemorrágicas y de mantener al paciente en rango óptimo de tratamiento. Sin embargo, requieren de una adecuada infraestructura y personal capacitado para que funcionen eficientemente. En este consenso argentino se propone una serie de parámetros para la gestión efectiva de una clínica de anticoagulación. El objetivo es lograr una elevada calidad desde el punto de vista clínico-asistencial a través de un laboratorio de hemostasia de excelencia. Los criterios desarrollados en el documento fueron consensuados por un amplio grupo de expertos especialistas en hematología y en bioquímica de todo el país. Estos criterios deben adaptarse a la irregular disponibilidad de recursos de cada centro, pero siempre se los debe tener en cuenta a la hora de indicar el tratamiento anticoagulante con estas drogas. Tener en consideración estas premisas nos permitirá optimizar la atención del enfermo anticoagulado con AVK y de esta forma minimizar las intercurrencias trombóticas y hemorrágicas a las que está expuesto, para así honrar nuestra promesa de no dañar al paciente.

Consenso argentino en gestión efectiva de clínicas de anticoagulación para uso de antagonistas de la vitamina K / Argentine consensus in effective management of anticoagulation clinics for the use of vitamin K antagonists

Resumen El tratamiento de un paciente anticoagulado con antagonistas de la vitamina K (AVK) sigue siendo un desafío, especialmente en regiones donde, por el costo, los dicumarínicos son todavía la alternativa más buscada a la hora de elegir un anticoagulante oral. Las clínicas de anticoagulación han demostrado ser la forma más eficiente y segura de evitar complicaciones trombóticas y hemorrágicas y de mantener al paciente en rango óptimo de tratamiento. Sin embargo, requieren de una adecuada infraestructura y personal capacitado para que funcionen eficientemente. En este consenso argentino se propone una serie de parámetros para la gestión efectiva de una clínica de anticoagulación. El objetivo es lograr una elevada calidad desde el punto de vista clínico-asistencial a través de un laboratorio de hemostasia de excelencia. Los criterios desarrollados en el documento fueron consensuados por un amplio grupo de expertos especialistas en hematología y en bioquímica de todo el país. Estos criterios deben adaptarse a la irregular disponibilidad de recursos de cada centro, pero siempre se los debe tener en cuenta a la hora de indicar el tratamiento anticoagulante con estas drogas. Tener en consideración estas premisas nos permitirá optimizar la atención del enfermo anticoagulado con AVK y de esta forma minimizar las intercurrencias trombóticas y hemorrágicas a las que está expuesto, para así honrar nuestra promesa de no dañar al paciente.

Abstract Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.

Totally Implantable Venous-Access Device Infection Causing Hematogenous Prosthetic Joint Infection: A Retrospective Case Series.

Introduction: Prosthetic joint infections (PJIs) can be acquired hematogenously from a distant site or device. Notably, 30%-40% of patients with PJIs have Staphylococcus aureus bacteremia. No case reports or series of PJIs acquired from totally implantable venous-access device (TIVAD) infection or colonization have been published. This study was undertaken to describe epidemiological, clinical, microbiological and radiological characteristics of such PJIs, their treatments and outcomes. Methods: This retrospective study included all patients, identified in a prospective French Bone-and-Joint Infections Referral Center cohort treated between 2004 and 2017, with PJI secondary to TIVAD infection, with the same microbiologically documented microorganism isolated from both. Results: We describe six consecutive hematogenous PJIs (4 women, 2 men; median age: 66.5 years) acquired from TIVAD primary infections. The main infection risk factors were malignancy (n=5) and prior septic arthritis (n=2). Four participants' TIVADs were implanted for chemotherapy, preceding the prosthesis for one patient. The median TIVAD-implantation-to-symptom-onset interval was 12 months. Microorganisms were Staphylococcus epidermidis (n=4), Staphylococcus capitis (n=1) and Staphylococcus aureus (n=1). All TIVADs were removed. Five participants received curative treatment, with a median of 12 weeks of antibiotics. After median follow-up of 42 months, none have relapsed. Conclusions: When PJI occurs in a patient with a TIVAD, the latter must be tested as a potential source of the prosthesis infection. Conversely, PJIs must sought in all patients with bacteremia.

Efficacy of Water Resistance Therapy in Subjects Diagnosed With Behavioral Dysphonia: A Randomized Controlled Trial.

PURPOSE: The purpose of the present study was to determine the efficacy of water resistance therapy (WRT) in a long-term period of voice treatment in subjects diagnosed with voice disorders. METHODS: Twenty participants, with behavioral dysphonia, were randomly assigned to one of two treatment groups: (1) voice treatment with WRT, and (2) voice treatment with tube phonation with the distal end in air (TPA). Before and after voice therapy, participants underwent aerodynamic, electroglottographic, acoustic, and auditory-perceptual assessments. The Voice Handicap Index and self-assessment of resonant voice quality were also performed. The treatment included eight voice therapy sessions. For the WRT group, the exercises consisted of a sequence of five phonatory tasks performed with a drinking straw submerged 5 cm into water. For the TPA, the exercises consisted of the same phonatory tasks, and all of them were performed into the same straw but the distal end was in air. RESULTS: Wilcoxon test showed significant improvements for both groups for Voice Handicap Index (decrease), subglottic pressure (decrease), phonation threshold pressure (decrease), and self-perception of resonant voice quality (increase). Improvement in auditory-perceptual assessment was found only for the TPA group. No significant differences were found for any acoustic or electroglottographic variables. No significant differences were found between WRT and TPA groups for any variable. CONCLUSIONS: WRT and TPA may improve voice function and self-perceived voice quality in individuals with behavioral dysphonia. No differences between these therapy protocols should be expected.

Coumarin heterocyclic derivatives: chemical synthesis and biological activity.

This review highlights the broad range of science that has arisen from the synthesis of coumarin-linked and fused heterocycle derivatives. Specific topics include their synthesis and biological activity.

Increased levels of cardiac troponin-T in outpatients with heart failure and preserved systolic function are related to adverse clinical findings and outcome.

BACKGROUND: The implications of increased levels of cardiac troponin T in congestive heart failure with preserved systolic function have been poorly evaluated. We hypothesized that its presence might be related to disease severity and prognosis in this setting. METHODS: Clinical, echocardiographic, 6-min walking test and laboratory data were prospectively obtained in 69 congestive heart failure outpatients with ejection fraction > or = 40%. Serial blood samples were assayed for cardiac troponin T with a third-generation immunoassay and values > or = 0.02 ng/ml were considered abnormal. RESULTS: Abnormal cardiac troponin T levels in at least one sample were found in 27 patients (39%, group 1). These patients were older (71.7 +/- 11 vs. 63 +/- 12.4 years, P = 0.002); more frequently hospitalized during the previous year (63 vs. 26.2%, P = 0.003), had lower systolic blood pressure (129.3 +/- 19.6 vs. 140.4 +/- 23.5 mmHg, P = 0.04), but had similar proportion of ischemic etiology (55.6 vs. 42.9%, P = 0.21) than those with normal cardiac troponin T (group 2). In groups 1 and 2, the functional class was 2.8 +/- 0.8 and 2.1 +/- 0.9 (P = 0.03), and the distance covered in 6 min was 339 +/- 100 and 386 +/- 103 m (P = 0.05), respectively. In groups 1 and 2, the 18-month congestive heart failure hospitalization-free survival was 22 and 87%, respectively (log-rank test P = 0.0003). In a Cox-proportional hazard model, functional class III-IV (hazard ratio = 5.21, 95% confidence interval: 1.43-18.96) and myocardial injury (hazard ratio = 5.51, confidence interval: 1.58-19.24) were independently associated with prognosis. CONCLUSION: Increased levels of cardiac troponin T were detected in one out of three congestive heart failure outpatients with preserved systolic function and correlated with clinical measures of disease severity and poor outcome. These findings suggest a link between ongoing myocardial injury and progressive impairment in congestive heart failure despite preserved systolic function.

Importance of early combined N-terminal pro-brain natriuretic peptide and cardiac troponin T measurements for long-term risk stratification of patients with decompensated heart failure.

BACKGROUND: Markers of myocardial necrosis and natriuretic peptides are risk predictors in decompensated heart failure (DHF). We prospectively studied the optimal timing of combined cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) measurements for long-term risk stratification. METHODS: cTnT and NT-proBNP were measured upon admission, and before discharge in 76 patients hospitalized for DHF (mean age 62.3 +/- 15 years; 71% men). RESULTS: During a mean follow-up of 252 +/- 120 days, 39.5% of patients died or were re-hospitalized for DHF. From receiver-operator-characteristic (ROC) curves, the selected cut-off values for cTnT and NT-proBNP were 0.026 ng/ml and 3,700 pg/ml on admission, and 0.030 ng/ml and 3,200 pg/ml, respectively, at discharge. Depending upon measurements above vs below cut-off, the population was distributed on admission and before discharge for three groups: both negative (24% and 30% of patients); one positive (43% and 42%); and both positive (33% and 28%). For the admission groups, the 1-year DHF-free re-hospitalization survival rates were 85%, 60% and 34%, respectively (p = 0.0047). One-year survival rates for DHF-free re-hospitalization were 63%, 71% and 26% (p = 0.0029), respectively, for the discharge groups. In the Cox proportional hazards model, systolic blood pressure (hazard ratio [HR]: 0.98; 95% confidence interval [CI]: 0.96 to 0.99), heart rate (HR: 0.97; 95% CI: 0.94 to 0.98), one positive biomarker on admission (HR: 10.5; 95% CI: 1.3 to 83.7) and two positive biomarkers on admission (HR: 13.9; 95% CI: 1.8 to 98.5) were independent predictors of long-term outcomes. However, NT-proBNP on admission was the most important predictor of long-term prognosis (HR: 5.1; 95% CI: 2.3 to 12.2). CONCLUSIONS: The combined measurements of cTnT and NT-proBNP on hospital admission were more reliable than their measurements before discharge in the long-term risk stratification of DHF. A single positive measurement on admission predicted a poor long-term outcome.

In vitro study of the effect of Er: YAG laser irradiation on the apical sealing of different root canal sealers%Estudo "in vitro" do efeito da irradiação do laser Er: YAG no selamento apical de diferentes tipos de cimentos obturadores

OBJETIVOS: Avaliou-se a infiltração marginal apical em caninos superiores, obturados com quatro tipos diferentes de cimento, os quais foram imersos em tinta nanquim e mantidos a uma temperatura de 37º C por 96 horas, descalcificados em solução de ácido clorídrico a 5 por cento, desidratados em série crescente de álcoois e diafanizados em salicilato de metila. MÉTODOS: Para isto, 64 dentes de estoque foram instrumentados pela técnica "crown-down", irrigados com solução de hipoclorito de sódio a 0,5 por cento e divididos em dois grupos experimentais. Os dentes do Grupo I foram subdivididos em quatro sub-grupos de oito elementos e obturados cada um deles com os cimentos Endofill«, N-Rickert«, Sealapex« e Sealer 26«. Os dentes do Grupo II receberam aplicação adicional de laser Er:YAG, tendo seus canais radiculares obturados como aqueles do grupo I. RESULTADOS: A infiltração marginal apical apresentou valores estatisticamente maiores e significantes (p < 0,01), nos dentes obturados com o cimento Endofill«, em relação à infiltração ocorrida nos dentes obturados com os cimentos N-Rickert«, Sealapex« e Sealer 26«. Não houve diferença estatística significante (p > 0,05), quanto à infiltração marginal apical, nos dentes do Grupo I, preparados somente com a solução de hipoclorito de sódio a 0,5 por cento, e naqueles do Grupo II, que foram irradiados com laser Er: YAG. CONCLUSÕES: A irradiação de laser Er:YAG aplicada nas paredes do canal radicular não foi capaz de prevenir a infiltração marginal apical

In vitro study of the effect of Er: YAG laser irradiation on the apical sealing of different root canal sealers

OBJECTIVES: The aim of this study was to determine the effect of Er:YAG laser irradiation used to clean dentinal walls on the apical sealing of root canals filled with different types of sealers. Background Data: Laser application to the dentinal walls removed debris, rendering the root canals free of smear layers and leaving the dentinal canaliculi open. METHODS: Sixty-four maxillary canines obtained from laboratory files were instrumented with K-files (Dentsply, Maillefer, Ballaigues, Switzerland) using the crown-down technique, and irrigated with a 0.5 percent sodium hypochlorite solution. The specimens were divided into two groups of 32 teeth each. In group I, the teeth were instrumented and irrigated with sodium hypochlorite solution, and divided into four subgroups to be sealed with the different materials (Endofill, N-Rickert, Sealapex and Sealer 26). In group II, the root canals were subjected to Er:YAG laser irradiation (200 mJ, 7 Hz and 60 J total energy), followed by root canal sealing as in group I. RESULTS: The data showed lower levels of apical microleakage in the teeth filled with N-Rickert, Sealapex and Sealer 26 cements than in those sealed with Endofill (p < 0.01). No significant difference in microleakage was observed between teeth irrigated only with 0.5 percent sodium hypochlorite and those submitted to Er:YAG laser application (p > 0.05). CONCLUSIONS: The Er:YAG laser irradiation applied to the root canal walls was not able to prevent apical microleakage.

OBJETIVOS: Avaliou-se a infiltração marginal apical em caninos superiores, obturados com quatro tipos diferentes de cimento, os quais foram imersos em tinta nanquim e mantidos a uma temperatura de 37° C por 96 horas, descalcificados em solução de ácido clorídrico a 5 por cento, desidratados em série crescente de álcoois e diafanizados em salicilato de metila. MÉTODOS: Para isto, 64 dentes de estoque foram instrumentados pela técnica "crown-down", irrigados com solução de hipoclorito de sódio a 0,5 por cento e divididos em dois grupos experimentais. Os dentes do Grupo I foram subdivididos em quatro sub-grupos de oito elementos e obturados cada um deles com os cimentos Endofill®, N-Rickert®, Sealapex® e Sealer 26®. Os dentes do Grupo II receberam aplicação adicional de laser Er:YAG, tendo seus canais radiculares obturados como aqueles do grupo I. RESULTADOS: A infiltração marginal apical apresentou valores estatisticamente maiores e significantes (p < 0,01), nos dentes obturados com o cimento Endofill®, em relação à infiltração ocorrida nos dentes obturados com os cimentos N-Rickert®, Sealapex® e Sealer 26®. Não houve diferença estatística significante (p > 0,05), quanto à infiltração marginal apical, nos dentes do Grupo I, preparados somente com a solução de hipoclorito de sódio a 0,5 por cento, e naqueles do Grupo II, que foram irradiados com laser Er: YAG. CONCLUSÕES: A irradiação de laser Er:YAG aplicada nas paredes do canal radicular não foi capaz de prevenir a infiltração marginal apical.

In vitro study of the effect of Er:YAG laser irradiation on the apical sealing of different root canal sealers.

OBJECTIVES: The aim of this study was to determine the effect of Er:YAG laser irradiation used to clean dentinal walls on the apical sealing of root canals filled with different types of sealers. BACKGROUND DATA: Laser application to the dentinal walls removed debris, rendering the root canals free of smear layers and leaving the dentinal canaliculi open. METHODS: Sixty-four maxillary canines obtained from laboratory files were instrumented with K-files (Dentsply, Maillefer, Ballaigues, Switzerland) using the crown-down technique, and irrigated with a 0.5% sodium hypochlorite solution. The specimens were divided into two groups of 32 teeth each. In group I, the teeth were instrumented and irrigated with sodium hypochlorite solution, and divided into four subgroups to be sealed with the different materials (Endofill, N-Rickert, Sealapex and Sealer 26). In group II, the root canals were subjected to Er:YAG laser irradiation (200 mJ, 7 Hz and 60 J total energy), followed by root canal sealing as in group I. RESULTS: The data showed lower levels of apical microleakage in the teeth filled with N-Rickert, Sealapex and Sealer 26 cements than in those sealed with Endofill (p < 0.01). No significant difference in microleakage was observed between teeth irrigated only with 0.5% sodium hypochlorite and those submitted to Er:YAG laser application (p > 0.05). CONCLUSIONS: The Er:YAG laser irradiation applied to the root canal walls was not able to prevent apical microleakage.

Atorvastatin has an important acute anti-inflammatory effect in patients with acute coronary syndrome: results of a randomized, double-blind, placebo-controlled study.

BACKGROUND: C-reactive protein (CRP) levels are associated with cardiovascular risk. We assessed the hypothesis that atorvastatin might have anti-inflammatory effects in acute coronary syndromes (ACS) as shown by CRP reduction. METHODS: This study was a prospective, randomized, double-blind, placebo-controlled study of 90 consecutive patients admitted within 48 hours of onset of ACS with CRP levels > or =1.4 mg/dL. Patients were assigned to atorvastatin 40 mg daily or placebo over 30 days. C-reactive protein levels, lipid profiles, serum fibrinogen, white cell count, and erythrocyte sedimentation rate were measured at entry, hospital discharge, and 1 month later. RESULTS: Baseline clinical characteristics did not differ between atorvastatin and placebo groups (mean age 59.3 +/- 13.4 vs 61.1 +/- 11.5, P = ns); myocardial infarction 52.3% versus 67.4% ( P = ns). In both groups, median baseline CRP levels were comparable (5.97 +/- 6.2 vs 4.64 +/- 4.2 mg/dL, P = ns). C-reactive protein levels were lower in the atorvastatin group versus control group at discharge (1.68 +/- 1.65 vs 4.12 +/- 4.18 mg/dL) and at 30 days (0.50 +/- 0.71 vs 2.91 +/- 2.68 mg/dL, both P < .0001). C-reactive protein levels significantly decreased from baseline to discharge and 1 month later in placebo and atorvastatin groups (both P < .0001); however, the reduction was greater in the atorvastatin group (62% vs 11% at discharge [P < .0001]; 84% vs 30% at 1 month [P < .0001]). In addition, atorvastatin was associated with a reduction in total and low-density lipoprotein cholesterol and erythrocyte sedimentation rate at discharge and at 30 days (P < .0001 for all comparisons). No correlation was found between changes in CRP and cholesterol levels. CONCLUSIONS: C-reactive protein levels in ACS were rapidly reduced with atorvastatin. These data provide evidence that statins have fast and early anti-inflammatory effects in addition to lipid-lowering effects in ACS.

Minor myocardial damage detected by troponin T is a powerful predictor of long-term prognosis in patients with acute decompensated heart failure.

BACKGROUND: The progression of chronic heart failure (CHF) is characterized by frequent exacerbation requiring hospitalization and high mortality. Clinical deterioration is triggered by many factors that could promote ongoing myocytes injury. We sought to determine whether a specific marker of cardiac injury, troponin T (cTnT), is associated with prognosis in acute decompensated heart failure (ADHF). METHODS: One hundred and eighty-four consecutive patients with ADHF were enrolled in the absence of an acute coronary syndrome. A cTnT value> or =0.1 ng/ml in samples drawn at 6, 12 or 24 h after hospital admission was considered abnormal. RESULTS: Increased levels of cTnT were found in 58 patients (31.5%, group 1). There were no significant differences between group 1 and patients with cTnT<0.1 ng/ml (group 2) in terms of demographic and clinical characteristics, although ischemic etiology was more prevalent in group 1 (51.7% vs. 31.7%, p=0.009). During follow-up, the mortality in groups 1 and 2 was 31% and 17.5% (p=0.038, OR=2.13, 95% CI: 1.03-4.69), respectively. The 3-year free-CHF readmission survival in group 1 and 2 was 25% and 53% (log rank test p=0.015). In a Cox proportional hazard model, poor tissue perfusion (HR=2.46, 95% CI=1.31-4.6), previous infarction (HR=1.99, 95% CI=1.02-3.9) and cTnT> or =0.1 ng/ml (HR=1.74, 95% CI=1.05-2.9) emerged as the independent predictors of long-term outcome. CONCLUSIONS: One third of patients with decompensated CHF had elevated levels of cTnT. Troponin T was an independent long-term prognostic marker of morbidity and mortality and it suggests a role of biochemical risk stratification in this setting.

Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema.

BACKGROUND: The clinical determinants of increased cardiac troponin T (cTnT) in patients with acute cardiogenic pulmonary edema are not well defined, and the ability of this marker to predict long-term mortality has not yet been documented. METHODS: Eighty-four patients with acute cardiogenic pulmonary edema without acute myocardial infarction were prospectively enrolled. cTnT was measured in samples obtained 6 and 12 hours after admission. RESULTS: cTnT levels of 0.1 ng/mL or greater were found in 46 patients (55%). Thirty-two patients (38%) died during follow-up. The area under the receiver operating characteristic curve for cTnT was 0.70 and 0.69 at 6 and 12 hours (P =.47), and the cTnT cutoff value of 0.1 ng/mL was 66% and 69% sensitive and 63% and 71% specific, respectively, in predicting subsequent mortality. Patients were assigned to group 1 if they had cTnT lower than 0.1 ng/mL and to group 2 if they had cTnT levels of 0.1 ng/mL or greater. A history of coronary artery disease was present in 72% of group 2 versus 50% of group 1 patients (P =.04). Patients in group 2 were also older than those in group 1 (mean age, 68 years vs 61 years; P =.021). The 3-year survival in group 1 was 76% compared with 29% in group 2 (log-rank test, P <.001). In a Cox proportional hazards model, elevated cTnT emerged as the only prognostic marker of long-term mortality (risk ratio [RR] = 2.31; 95% CI, 1.011-5.280; P =.047). CONCLUSIONS: A cTnT level of 0.1 ng/mL or greater was associated with poor long-term survival and emerged as a powerful independent predictor of mortality in patients with acute cardiogenic pulmonary edema.

Indicadores pronósticos en la angina inestable: papel de la troponina T cuantitativa / Prognostic markers in unstable angina: role of the quantitative T-troponine determination

Con el objetivo de identificar marcadores pronósticos en la angina inestable fueron incluídos en este estudio 335 pacientes, a quienes se les realizaron determinaciones de CPK, CK-MB y troponina T entre 6 y 24 horas. A 30 días el 21,9 por ciento tuvo una angina refractaria y el 11,4 por ciento sufrió infarto o murió. Una troponina T mayor o igual 0,1 ng/ml fue considerada positiva, detectándose en el 23,7 por ciento. La angina recurrente y una troponina T > 0,1 ng/ml se asociaron, en el análisis multivariado, con la evolución a infarto o muerte; mientras que ambos predictores, el angor de reposo y el alto riesgo inicial, son marcadores independientes de la evolución a infarto, óbito o angina refractaria