Back pain in a Bangladeshi worker in Iraq.

Pyogenic Spinal Infection (PSI) is an uncommon disorder encompassing a broad spectrum of diseases including septic spondylodiscitis, osteomyelitis, epidural and paravertebral abscess formation. Presentation can be vague and highly variable but usually includes back pain and fever. Whilst predisposing factors, such as trauma and diabetes can often be identified a pathogenic organism may not be identified in up to a half of all cases leading to significant delay in both accurate diagnosis and effective treatment. Precise spinal imaging is essential and includes plain X-ray, CT and preferably MRI. The treatment of PSI can be conservative (including antibiotics); however, spinal surgery may be required for the complications in up to 50% of cases, with varying degrees of success. We present a challenging case of PSI encountered in a locally-employed 42-year-old Bangladeshi civilian working in Iraq. Despite obvious resource limitations available within a Role 2 Field Hospital, clinical suspicion coupled with repeat spinal CT was pivotal in obtaining the diagnosis. The patient was repatriated to Bangladesh for MRI and definitive surgical treatment.

Randomized comparison of coronary stent implantation and balloon angioplasty in the treatment of de novo coronary artery lesions (START): a four-year follow-up.

OBJECTIVE: The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty. BACKGROUND: Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials. METHODS: We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up. RESULTS: Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 +/- 0.6 mm vs. 1.43 +/- 0.6 mm in the angioplasty group; p < 0.0001), and at six-month follow-up (1.98 +/- 0.7 mm vs. 1.63 +/- 0.7 mm; p < 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p < 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p = 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study. CONCLUSIONS: Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.

Validity of anthropometry- and impedance-based equations for the prediction of total body water as measured by deuterium dilution in Cameroonian haemodialysis patients.

BACKGROUND & AIMS: There is no available information on the validity of anthropometry- and impedance-based equations for predicting total body water (TBW) in Cameroonian haemodialysis patients. This study aimed to validate and develop predictive equations of TBW for Cameroonian haemodialysis patients. METHOD: TBW in 40 Cameroonian haemodialysis patients (28 men and 12 women) was measured by deuterium dilution and compared with the one predicted by 7 anthropometric and 9 BIA equations. Multiple linear regression analysis was used to develop an equation for predicting TBW as measured by deuterium, from anthropometric parameters. RESULTS: Pure errors in predicting TBW showed unacceptable value for all equations tested. In all the cases, unacceptable discrepancies at individual level for clinical purposes were noted. The following equation was developed and showed a better agreement with the deuterium dilution method: TBW = 13.8994 + 0.0017 × Age +0.3190 × Weight +1.8532 × Sex. CONCLUSION: Further development and cross-validation of anthropometric and BIA prediction equations specific to African heamodialysis patient are needed. Meanwhile, the equation developed in this study which provided a better agreement with the isotope dilution could be use for Cameroonian haemodialysis patients.

Polymorphism of the platelet glycoprotein IIIa gene in patients with coronary stenosis.

Based on genetic variability, structural differences in the glycoprotein IIb/IIIa platelet receptor for adhesive proteins result in individual differences in the thrombogenicity of platelets. Recent studies suggest a controversial association between a genetic polymorphism of the glycoprotein IIIa gene (PlA2) and the risk of coronary artery disease. In our study, the prevalence of the PlA2 allele in a group of patients undergoing percutaneous coronary revascularization was 37%, a value significantly higher than in controls [13%, odds ratio (OR) = 3.93, 95% CI, 1.84 to 8.53] suggesting a significant association between this polymorphism and documented coronary stenosis, which is strongest among <60 years old patients (OR = 12.30, 95% CI, 2.98 to 70.93). This polymorphism represents an inherited risk factor for severe cardiovascular disease due to coronary occlusion.

Analysis of the amount of tricuspid valve anular dilatation required to produce functional tricuspid regurgitation.

To determine the critical anular dilatation required for functional tricuspid regurgitation (TR) and the role of systolic anular shortening in the severity of TR, 67 patients in whom right ventriculography had been performed were studied. These patients were classified into group I, control (n = 12), and the group II, patients with rheumatic valvular disease (n = 55). Group II patients were subclassified as follows: IIa, without TR (n = 19); IIb, with mild TR (n = 22); and IIc, with moderate to severe TR (n = 14). The angiographic maximal early systolic and minimal end-systolic diameters were measured. The shortening of the tricuspid anulus was expressed as percent reduction of the maximal diameter. The average maximal diameter (mm/m2) was: group I, 21 +/- 2; group IIa, 24 +/- 2; group IIb, 31 +/- 4; and group IIc, 37 +/- 4. The average minimal diameter (mm/m2) was: group I, 15 +/- 2; group IIa, 18 +/- 2; group IIb, 23 +/- 2; and group IIc, 31 +/- 3. The average percent shortening was: group I, 30 +/- 7%; group IIa, 25 +/- 7%; group IIb, 26 +/- 5%; and group IIc, 15 +/- 3%. The rheumatic patients had a larger maximal diameter than did those in the control group. Anular shortening was reduced only in the group with moderate to severe TR and preserved in the other groups, including those with mild TR. The critical diameter was determined to be between the maximal diameter in the rheumatic patients without TR and the minimal diameter in the patients with moderate to severe TR, or 27 mm/m2. Thus this easily measured parameter can determine the presence and significance of functional TR, adding objectivity to the angiographic diagnosis of TR.

Coronary arteriography and atrial thrombosis in mitral valve disease.

The arteriographic findings of neovascularity and fistula formation from the coronary arteries to the left atrium have occasionally been reported in association with atrial thrombosis in patients with mitral valve disease. To establish the diagnostic value of these findings, the preoperative coronary angiograms of 507 patients who underwent open mitral valve surgery were reviewed. Atrial thrombosis was present in 76 patients (14.9 percent). In the 30 patients with angiographic neovascularity and fistula formation, the thrombi were always observed to arise from the circumflex coronary artery. None of these 30 patients had atherosclerotic coronary lesions. In 25 of these patients an atrial thrombus was found at operation. These coronary arteriographic findings, in this selected group of patients, had a predictive accuracy of 83.3 percent, a specificity of 98.8 percent and a sensitivity of 32.8 percent for the diagnosis of the presence of thrombus in the left atrium. No relation was found between these signs and the size and histologic age of the thrombi examined.

Evaluation of direct stent implantation without predilatation by intravascular ultrasound.

The present study shows that direct stent implantation without predilatation in selected lesions provides angiographic and ultrasonographic results that could be comparable to those expected with conventional stenting. These results may even safely improve if a balloon-artery ratio of 1.1 to 1.2 is used in combination with implantation pressures of 12 to 16 atm.

Stenting the stent: initial results and long-term clinical and angiographic outcome of coronary stenting for patients with in-stent restenosis.

Stent restenosis constitutes a therapeutic challenge affecting an increasing number of patients. Conventional angioplasty and debulking techniques are currently used in these patients. However, the potential role of a second stent implantation in this setting (stenting the stent) remains unknown. Therefore, 65 consecutive patients (12 women, aged 62 +/- 11 years) undergoing stent implantation (42 elective and 23 unplanned) for the treatment of in-stent restenosis (diffuse [> 10 mm] in 39 [60%]) were studied. Angiographic success was obtained in all patients. Three patients developed hospital complications: 1 died from refractory heart failure and 2 suffered non-Q-wave myocardial infarctions. During follow-up (mean 17 +/- 11 months) 1 patient died (noncardiac cause) and only 9 (14%) required target vessel revascularization. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and target vessel revascularization) at 1 year was 84%. Using Cox analysis, patients with unstable symptoms, a short time to stent restenosis, nonelective stenting, and B2-C lesions tended to have poorer prognosis. After adjustment, nonelective stenting was associated (adjusted RR 2.9, 95% confidence interval [CI] 0.82 to 10.3, p = 0.09) with an adverse clinical outcome. On quantitative angiography (core lab) restenosis was found in 13 of 43 patients (30%) (75% of those eligible). Logistic regression analysis identify restenosis length (adjusted RR 1.43, 95% CI 1.04 to 2.14, p = 0.04), and time to restenosis (adjusted RR 0.67, 95% CI 0.47 to 0.94, p = 0.01) as the only independent predictors of recurrent restenosis. Thus, repeat coronary stenting is a safe and efficacious strategy for the treatment of patients with in-stent restenosis. Both elective and nonelective stenting provide excellent initial results. The long-term clinical and angiographic outcome of these patients is also favorable.

Is tricuspid valve repair necessary?

In an attempt to clarify the indications for tricuspid valve operations, we studied 150 patients who had preoperative and postoperative full catheterization including biventriculography. Seventy-eight patients had organic and 72 had functional tricuspid insufficiency (TI). One hundred nineteen underwent tricuspid repair (46 commissurotomies and 115 annulopasties), and in 31 the tricuspid disease was surgically ignored. Ninety seven percent of all patients with hemodynamically correct left-side repair were in Class I or II, regardless of the state of the tricuspid valve. Repair of lesions on the left side determined the postoperative cardiac index. In the "repaired group," 38% had residual gradients and 30% residual TI. Eighty percent of patients with low postoperative pulmonary resistance had no TI, compared with 53% with high pulmonary resistance. In the "ignored group," all 14 patients with organic disease had residual TI, as did nine of 17 with functional disease but with elevated pulmonary resistance. The right ventricular end-diastolic volume (RVEDV) decreased 37% in the "repaired" (p < 0.001) and 36% in the "ignored" group (p < 0.01) if tricuspid competence was achieved, but remained high if TI persisted. Because of these data, which emphasize the need for an early and correct repair of the left-side lesions, we believe that (1) functional TI can be ignored only in patients with predictable and significant reduction in pulmonary resistance and (2) organic disease must be repaired.

Open mitral commissurotomy.

We analyzed the results obtained in 163 consecutive patients with "pure" mitral stenosis who underwent operation by the open approach exclusively. Calcification was found in the mitral valve leaflets in 11% of the patients and left atrial thrombus, in 13.2%. A statistically significant relationship was discovered between history of previous systemic embolism and cardiac rhythm (p less than 0.005). The subvalvular apparatus was affected in 66.6% of patients; most of them were in New York Heart Association Functional Class III (p less than 0.005). The frequency with which annuloplasty had to be performed because of mitral insufficiency after commissurotomy was statistically higher (p less than 0.025) among patients in Functional Class III. Early mortality was 1.2% and late mortality, 0.2% per patient-year. Two patients required late reoperation (0.4% per patient-year). One was in Functional Class III and the other, Functional Class IV before the first operation. Three patients sustained a late systemic embolism (0.6% per patient-year). All survivors but 1 are in Functional Class I (84.4%) or II (14.9%).

Balloon mitral commissurotomy in patients with previous annuloplasty. Our experience.

Balloon mitral commissurotomy is an alternative to surgical commissurotomy in the treatment of mitral stenosis and different studies have shown its usefulness for restenosis following surgical commissurotomy. We describe our experience in balloon mitral commissurotomy in five patients with previous commissurotomy and annuloplasty. Among 360 balloon commissurotomies performed in our hospital up to December 1993, 29 procedures were performed on patients with restenosis after surgical commissurotomy, five of whom also had an annuloplasty (flexible ring in four and rigid in one). The balloon commissurotomy was performed without complications using the Inoue single balloon technique. Mitral valve area increased from 0.9 +/- 0.1 cm2 to 1.0 +/- 0.1 cm2 by pressure half-time, and from 1.0 +/- 0.2 cm2 to 1.3 +/- 0.1 cm2 by Gorlin formula. Two patients in functional class III underwent mitral valve replacement, 32 and 11 months later; the other three patients were in class II 38, 10 and 7 months later. The presence of a mitral ring should not constitute a contraindication to balloon commissurotomy. However, the haemodynamic results are not favourable in our patients, probably due to the practical absence of commissural fusion and the ring's restrictive effect on valvular stretching.

Differences in response to single dose and steady-state therapy with verapamil in stable angina.

Ten patients with stable effort angina were studied in a randomized double-blind and placebo-controlled trial to compare the antianginal efficacy of "acute" and "chronic" (after reaching a steady-state level) treatment with verapamil. Efficacy was assessed by exercise testing after a 120 mg single-dose and at the end of a seven-dose course of 120 mg of verapamil given thrice daily. Three daily exercise tests were performed the first, second and fifth day of the study protocol at 8, 12 and 16 hours. Eight hours after the last dose was given, exercise time increased by 54 +/- 30 sec after a single-dose of verapamil and by 156 +/- 31 sec after seven-doses of verapamil (P less than 0.05 as compared to single-dose verapamil). The time to 1 mm depression of the ST segment increased by 30 +/- 20 sec after a single-dose of verapamil and by 66 +/- 28 sec after seven-doses of verapamil (P less than 0.01 as compared to single dose verapamil). Six of the ten patients became free from angina on treadmill exercise after a seven-dose course of verapamil, but only one patient became free from angina after acute testing with a single-dose of verapamil. It is concluded that several doses of verapamil are required to achieve an optimal anti-ischemic effect, as suggested by the pharmacodynamic properties of this drug. Once steady-state is achieved, the effects of verapamil remain for at least 8 hours, so that an administration schedule of three times daily protects the patient for a 24-hour period.

Structural modification of berberine alkaloids in relation to cytotoxic activity in vitro.

The cytotoxicity of two protoberberine alkaloids: berberine and lincangenine, their 8-hydroxy-7,8-dihydro-derivatives and tetrahydroprotoberberine:thaicanine, was evaluated. The cellular responses through the [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide] (MTT) method were measured in Hela (uterus carcinoma), SVKO3 (ovary carcinoma), Hep-2 (larynx carcinoma), primary culture from mouse embryon, and human fibroblast cells at the concentration: 10-1000 ppm (microg/ml) for 24 h. Berberine showed the highest cytotoxicity among the compounds tested, giving LC50 values for all cell lines at the concentration of 10 ppm. The results indicated that the cytotoxicity was notably decreased by structural changes, i.e. by modulation of the planarity caused by the introduction of hydroxyl group at C-8 and concomitant saturation of double bond between N-C8 in protoberberine molecules. In the case of berberine, the cytotoxic effect changed from 98.8 (berberine) to 39% for 8-hydroxydihydroberberine at the concentration of 100 ppm in Hela cells line. The same effect was observed with lincangenine and 8-OH-lincangenine (cytotoxicities 70 and 25%, respectively, at 1000 ppm in SVKO3 cells). On the other hand, these compounds showed a low selectivity for the different human cancer cell lines tested.

[Blood coagulation, genetics and post-angioplasty restenosis]. / Coagulación, genética y reestenosis postangioplastia.

Throughout the last few decades, different factors have been related to coronary stenosis which is clinically evidenced by coronary heart disease, the leading cause of death in developed countries. Different experimental models have contributed towards defining some of these factors, and to an understanding of the physiopathology of the atherosclerotic lesion. The genetic basis related to individual responses to the same event is currently being established. As endothelial injury reparative mechanisms are fundamental in atherosclerosis pathogeny, patients who experiment restenosis after undergoing revascularization procedures are useful human models in the study of these processes. We review from the literature the genetic factors related to thrombus formation, which may be associated with restenosis after percutaneous transluminal coronary angioplasty, in order to define the most suitable anticoagulant therapy for each patient. We refer to the recently characterized gene for the platelet receptors and its relationship with fibrinogenous, factor Xa, PAI-I, and the involvement of apolipoprotein (a) in the coagulation process.

[Evaluation using serial exercise tests of verapamil alone and combined with isosorbide dinitrate in exertional angina]. / Valoración mediante pruebas de esfuerzo seriadas del verapamil solo y combinado con dinitrato de isosorbide en la angina de esfuerzo.

The response to verapamil alone and combined with isosorbide dinitrate in a group of 12 patients with severe ischemic heart disease and stable effort angina was assessed by means of serial treadmill testing. The study was randomized, of a square latin design and double-blind. The tested drugs and dosages were 120 mg of verapamil, 120 mg of verapamil plus 20 mg of isosorbide dinitrate and placebo. Patients were serially tested (Bruce protocol) over three consecutive days at 8-9-12 and 16 hours. A significative improvement was observed in several ischemic parameters both with verapamil alone and combined with isosorbide dinitrate, but this improvement was remarkably enhanced with the combination of drugs. The mean exercise time to produce angina improved from 268 +/- 18 sec (basal) to 379 +/- 19 sec (verapamil plus isosorbide dinitrate) and the time for 1 mm ST segment depression from 163 +/- 22 sec (basal) to 257 +/- 19 sec (verapamil plus isosorbide dinitrate) when measured at the last daily test (8 hours after drug administration). It is concluded that both verapamil alone and combined with isosorbide dinitrate at the chosen doses are clinically efficient, significantly improving the ischemic parameters. The combination of verapamil and isosorbide dinitrate resulted in a remarkably better improvement in this group of patients with stable effort angina.

[Symptomatic ischemia in a patient with a single right coronary artery without lesions]. / Isquemia sintomática en un paciente con coronaria derecha única sin lesiones.

Coronary artery anomalies are not a frequent finding, and a single right coronary artery is extremely rare. This anomaly has been included among the potentially serious ones because its association with infarction and sudden death has been reported. We present the case of a female patient who complained of chest pain, showed a positive exercise treadmill test and had a single right coronary artery in the angiography with no stenotic lesions. The pathophysiology and the clinical implications are discussed.

[Anomalous origin of the circumflex artery from the pulmonary artery in a patient with rheumatic mitral stenosis]. / Origen anómalo de la arteria circunfleja en la arteria pulmonar en un paciente con estenosis mitral reumática.

Left circumflex coronary artery arising from the pulmonary artery is an infrequent congenital anomaly, only described once in an adult patient. We present one patient with rheumatic mitral stenosis in whom this anomaly was noticed when an angiography was performed prior to a percutaneous mitral valvuloplasty.

[Initial results and 6 month clinical follow-up after implantation of a silicon carbide coated coronary stent]. / Resultados iniciales y seguimiento clínico a 6 meses tras el implante de un stent coronario recubierto de carburo de silicio.

INTRODUCTION AND OBJECTIVES: To present the initial Spanish experience with the Tenax coronary stent, a laser sculpted from high-precision 316L stainless steel coated with hydrogen rich amorphous silicon carbide that reduces thrombogenecity and improves biocompatibility. PATIENTS AND METHODS: From July 1998 to July 1999, 206 patients (62 +/- 5 years) underwent implantation of 231 Tenax stents in 9 centers as the only revascularization procedure. The most frequent clinical indication was unstable angina (66%), and most of the lesions were complex (class B2 and C). The target vessels were the left anterior descending (51%) and right coronary arteries (36%). The ejection fraction was < 0.5 in 19% cases. RESULTS: Revascularization was complete in 70%, elective in 80%, and the implantation was direct in 25% of the cases. The procedure was successful in all the lesions, reducing stenosis from 62 +/- 16 to 16 +/- 10% and increasing the minimal luminal diameter from 0.81 +/- 0.40 to 2.61 +/- 0.59 mm. The TIMI flow was reduced in 30%, but normalized after the stent in all but one case. The incidence of cardiac events was minimal: 1 acute thrombosis (0.5%) resolved by a new angioplasty and 1 non-Q myocardial infarction (0.5%). At the 6-month clinical follow-up 10% of the patients presented complaints of angina greater than class II, and a new angioplasty was carried out in 1.9% of these cases. CONCLUSION: Clinical and angiographic data suggest that the hydrogenated silicon carbide coating of the Tenax coronary stent may indeed play a beneficial role in patient outcome, and should therefore be evaluated by prospective clinical trials.

[Wiktor coronary stent for elective placement with an antiaggregation regimen. WINE study. WINE Group Study]. / Stent coronario Wiktor por indicación electiva con régimen de antiagregación. Estudio WINE. Grupo de Estudio WINE.

INTRODUCTION AND OBJECTIVES: The main problems associated with coronary stent implantation are subacute thrombosis and vascular and hemorrhagic complications due to the intensive anticoagulant regime. We studied the complications and the six-month restenosis rate after the elective implantation of a Wiktor stent in patients treated only with antiplatelet drugs. PATIENTS AND METHODS: The WINE study is an open, observational, multicenter study that included 368 patients (380 lesions) from 11 Spanish hospitals. All patients were treated with aspirin (125-325 mg/day) and ticlopidine (250 mg/12 h for 4 weeks). After hospitalization, a clinical control and clinical and angiographic controls were performed at one and six months respectively. RESULTS: 27 patients were excluded after the procedure because of failed delivery of the stent (5 cases), suboptimal angiographic result (15 cases) or lack of adherence to the antithrombotic regime (7 cases). Among the 341 patients with an adequate result most lesions (76.2%) were type B, including 39.1% type B2 and 8.5% type C. Subacute stent occlusion occurred in two patients (0.6%). Seven patients (2.1%) had vascular complications related to the arterial puncture. No major hemorrhagic complications needing transfusion were found. At six months 64 patients (19.8%) showed angiographic restenosis. CONCLUSIONS: When the angiographic result after Wiktor stent placement is adequate, the therapy with aspirin and ticlopidine is associated with a very low stent thrombosis rate as well as with a low rate of vascular complications and 6 month angiographic restenosis.

[A direct stent without predilatation. Our experience in 300 lesions]. / Stent directo sin predilatación. Experiencia en 300 lesiones.

INTRODUCTION: The stent alone technique, direct stenting without predilatation, aims to reduce cost and procedural time. Other potential benefits are the avoidance of abrupt vessel closure after balloon angioplasty and lessening of the restenosis rate due to the reduced arterial injury. We present our experience with this therapeutic approach in a long series of patients. PATIENTS AND METHODS: 230 patients referred to our unit were included with 300 non-occlusive stenotic lesions without excessive tortuosity, calcification, length or angulation and with a reference vessel diameter > or = 2.5 mm. In these patients stent implantation without predilatation was attempted. The immediate angiographic results and procedural related complications were evaluated. RESULTS: The stent alone technique succeeded in 256 (85%) among the 300 lesions treated. In 43 (14.3%) lesions predilatation was required and in one case the stent could not be positioned. A new dilatation after deployment was required due to suboptimal stent expansion in 27/256 (10.5%) lesions. Stent embolization occurred in 5 patients, 4 stents were retrieved and there were no clinical sequelae. The best results were obtained in non-subtotal and non-bifurcated lesions type A or B1 without moderate calcification, tortuosity or angulation. CONCLUSIONS: Direct stenting is feasible in a large number of patients with a high success rate after an appropriate selection. The most optimal lesions to be treated with this technique are < or = 90% stenotic non-bifurcated lesions type A or B1 without moderate calcification, tortuosity or angulation.