Intra-articular hyaluronic acid injections for hip osteoarthritis.

Although viscosupplementation has been used in the past few years both for knee and hip osteoarthritis (OA), the number of intra-articular injections and the interval between doses still remains an undetermined subject. The aim of this open retrospective study was to evaluate the clinical and functional outcome in patients with mild-moderate hip OA treated with a course of 1, 2 or 3 Hyaluronic Acid (HA) intra-articular injections. Ninety-six patients were included: 19 patients received only one injection, 24 received two injections, and 44 received three injections. Age, sex, VAS for pain and WOMAC score before each intra-articular injection, number of intra-articular injections, reasons for interrupting the treatment, adverse events, time between HA injections, and number of patients who had a total hip replacement were retrieved from the medical records of each patient. VAS and WOMAC scores were obtained from all patients also at a mean follow-up of 7 months after the last hip injection. All patients who received 1, 2 or 3 hip injections improved in VAS and WOMAC score. Three intra-articular injections provided a better outcome in terms of pain reduction compared to 1 or 2 injections. Intrarticular injections for mild-moderate hip OA were demonstrated to be effective in reducing pain and improving function. A full course of three injections provided the best result in pain control.

Safety of intra-articular hip injection of hyaluronic acid products by ultrasound guidance: an open study from ANTIAGE register.

OBJECTIVE: We developed a standardized technique for ultrasound guided intra-articular injection of the hip joint with the purpose of extending routine intra-articular injection of hyaluronans and steroids to the hip, as commonly used in the knee. In this article we report the safety of this technique in an extended series of patients. PATIENTS AND METHODS: Patients were injected supine with an anterosuperior approach under ultrasound guidance. The Us probe is applied with a target device for biopsy. RESULTS: The standardised technique was used to inject 1906 patients with 4002 injections of hyaluronan products over a four-year period. The treatment was well tolerated with few, and exclusively local, side effects. CONCLUSIONS: The administration of hyaluronans under ultrasound-guided intra-articular injection is a safe technique for treatment of rheumatic diseases of the hip.

Allergen sensitizations in southern Italy: a 5-year retrospective study in allergic respiratory patients.

The assessment of the distribution of allergen skin test sensitizations is highly recommended for the optimal management of allergic respiratory conditions. We aimed at evaluating the distribution of allergen sensitizations in individuals with asthma and/or rhinitis in the Southern region of ltaly, and at exploring whether changes in the frequency of allergen sensitizations occurred after a 5-year period. Demographic data and skin prick test sensitizations to allergens from asthmatics and/or rhinitis attending the Division of Respiratory Diseases, University of Palermo, Italy in 2005 (Phase 1) and in 2010 (Phase 2) were extrapolated and retained for analysis. A total of 2033 allergic respiratory patients were included (1002 in Phase 1 and 1031 in Phase 2). In both investigations, the most prevalent allergen sensitization was towards Parietaria; however, a significant reduction in the rate of prevalence after 5 years was recorded (from 60% to 48% of skin test positive patients, p < 0.0001). Up to one out of two subjects showed sensitization to dust mites in both Phases. Interestingly, Cypress pollen sensitization almost doubled from Phase 1 (17%) to Phase 2 (29%; p < 0.0001). Overall, the mean number of skin test sensitizations for each patient increased from 2.7 +/- 1.6 in Phase 1 to 3.1 + 1.8 in Phase 2 (p < 0.0001). The present findings confirm the prevalent role of Parietaria sensitization in the allergic population of the Mediterranean area of Southern Italy, and document the increase of Cypress sensitization. These observations could contribute to a proper management of chronic allergic respiratory conditions in this region.

Hip viscosupplementation under ultra-sound guidance riduces NSAID consumption in symptomatic hip osteoarthritis patients in a long follow-up. Data from Italian registry.

INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAIDs) consumption is strictly related to a high gastrointestinal and cardiovascular mortality and morbidity rate. Osteoarthritis Research Society International (OARSI) recommendations in patients with symptomatic hip or knee OA stated that NSAIDs should be used at the lowest effective dose but their long-term use should be avoided if possible. OARSI guidelines for the treatment of the hip OA include the use of viscosupplementation, which aims to restore physiological and rheological features of the synovial fluid. OBJECTIVE: Aim of this multicentric, open and retrospective study is to investigate if NSAID consumption may be reduced by the use of ultrasound-guided intra-articular injection of several hyaluronic acid (HA) products in hip joint administered in patients affected by symptomatic hip OA. MATERIALS AND METHODS: Patients affected by mono or bilateral symptomatic hip OA according to American Rheumatology Association (ARA) criteria, radiological OA graded II-IV (Kellgren and Lawrence) entered the study and were administered with ultrasound-guided intra-articular injection of hyaluronic acid products. As a primary endpoint, consumption of NSAIDs was evaluated by recording the number of days a month (range 0-30) the patient had used NSAID during the previous month, reported at each visit during the 24 months follow-up period. Secondary endpoints included further analysis for subgroups of patients categorized for Lequesne index score, Kellgren-Lawrence score, pain visual analogue scale (VAS) score, ultrasound pattern, age, hyaluronic acid used. RESULTS: 2343 patients entered the study. Regarding primary endpoint, the consumption of NSAIDs was reduced of 48.2% at the third month when compared with baseline values. This sparing effect increased at 12th and 24th month with a reduction respectively of 50% and 61% in comparison to baseline values. These differences were statistically significant. CONCLUSIONS: These data point out that intraarticular hyaluronan preparations provide OA pain relief and reduce NSAIDs consumption in a large cohort of patients for a long period of follow-up. Multiple courses of viscosupplementation (vs) are required to maintain low dose of NSAID consumption over time. NSAIDs consumption is strictly related to an high gastrointestinal and cardiovascular mortality and morbidity rate, instead HA intra-articular treatment is well tolerated and is associated with a low incidence of adverse effects. For these reasons further studies evaluating cost-effectiveness and cost-utility of VS in the management of hip OA are required.

Quantitative relation between increased intrapericardial pressure and Doppler flow velocities during experimental cardiac tamponade.

To establish whether a quantitative relation exists between pericardial pressure and respiratory variation in intracardiac blood flow velocities, a spontaneously breathing closed chest canine model of pericardial tamponade was created. In seven dogs, pericardial pressure was sequentially increased in stages from a mean of -4 +/- 1 to 10 +/- 2 mm Hg while aortic and pulmonary Doppler flow velocities, pleural pressure changes (respiratory effort), blood pressure and cardiac output were measured. The variation in the Doppler-detected peak transaortic velocity (AV) during inspiration (IV) increased linearly from -5 +/- 3% at baseline (pericardial pressure -4 mm Hg) to -32 +/- 9% at a pericardial pressure of 10 mm Hg [IVAV = -2 (pericardial pressure)--13.1; r = 0.78, p less than 10(-6)]. The inspiratory variation in the peak transpulmonary velocity increased from 13 +/- 3% at baseline to 71 +/- 19% at a pericardial pressure of 10 mm Hg. The inspiratory variation in the pulmonary Doppler peak velocity (IVPV) was dependent on both pericardial pressure and degree of respiratory effort [IVPV = 3.8 (pericardial pressure) + 2.6 (respiratory effort) + 10.9; r = 0.88, p less than 10(-8)]. Thus, quantitative relations exist between increases in intrapericardial pressure and increases in inspiratory variation of peak aortic and pulmonary flow velocities. Additionally, pulmonary artery flow velocity is influenced more than aortic velocity by intrathoracic pressure.

Papillary muscle traction in mitral valve prolapse: quantitation by two-dimensional echocardiography.

Previous angiographic observations in patients with mitral valve prolapse have suggested that superior leaflet displacement results in abnormal superior tension on the papillary muscle tips that causes their superior traction or displacement. It has further been postulated that such tension can potentially affect the mechanical and electrophysiologic function of the left ventricle. The purpose of this study was to confirm and quantitate this phenomenon noninvasively by using two-dimensional echocardiography to determine whether superior displacement of the papillary muscle tips occurs and its relation to the degree of mitral leaflet displacement. Directed echocardiographic examination of the papillary muscles and mitral anulus was carried out in a series of patients with classic mitral valve prolapse and results were compared with those in a group of normal control subjects. Distance from the anulus to the papillary muscle tip was measured both in early and at peak ventricular systole. In normal subjects, this distance did not change significantly through systole, whereas in the patient group it decreased, corresponding to a superior displacement of the papillary muscle tips toward the anulus in systole (8.5 +/- 2.6 vs. 0.8 +/- 0.7 mm; p less than 0.0001). This superior papillary muscle motion paralleled the superior displacement of the leaflets in individual patients (y = 1.0x + 0.8; r = 0.93) and followed a similar time course.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications.

To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics. The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%). In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.

Quantitation and significance of systolic mitral leaflet displacement in mitral valve prolapse.

Superior systolic displacement of the mitral leaflets is the echocardiographic finding generally used to diagnose mitral valve prolapse, but its clinical significance is not clearly established. This study was designed to determine if the presence of leaflet thickening, displacement in the multiple imaging planes or the quantitative degree of displacement could be used to identify clinically important valvular abnormality. To this end, these findings were prospectively assessed and correlated with the presence of mitral regurgitation and ventricular arrhythmia in 49 patients with displacement and in 49 age-matched control subjects with no identifiable displacement. Both ventricular arrhythmia and mitral regurgitation were found to occur with significantly greater frequency in patients with leaflet displacement than in control subjects. However, among the patients with leaflet displacement, both these complications occurred with greater frequency in subgroups characterized by the presence of leaflet thickening, quantitatively greater displacement and displacement evident in 2 orthogonal imaging planes. Logistic regression analysis demonstrated that the best echocardiographic predictor of either ventricular arrhythmia or mitral regurgitation was the quantitative degree of leaflet displacement. These results indicate that most patients with echocardiographic evidence of leaflet displacement had very low incidences of ventricular arrhythmia and mitral regurgitation. Subgroups, however, could be identified echocardiographically in which both complications occurred with significantly greater frequency.

Baroreflex function and cardiac structure with moderate endurance training in normotensive men.

Changes in arterial and cardiopulmonary baroreflex function and cardiac structure were followed throughout 10 wk of moderate endurance training [60 min of cycling, 3 days/wk, 60% maximal O2 uptake (VO2max)] in sedentary normotensive men (22-34 yr old). Subjects were randomly assigned to an exercise training group (ET; n = 9) or to a control group (UT; n = 4). Decreases in resting heart rate (8.9 +/- 2.6%, P < 0.01) and mean arterial pressure (7.0 +/- 2.3%, P < 0.05) and an increase in VO2max occurred after 10 wk in ET. An increase in the gain or slope of the spontaneous baroreflex response at rest was found after 10 wk in ET (50.1 +/- 6.3%, P < 0.01) but not in UT. An upward shift in the resting carotid-cardiac baroreflex response curve also occurred after 10 wk in ET, although the maximum range and gain of the response and the vagally mediated peak reflex sinus node responses were unchanged. Cardiopulmonary baroreflex function (reflex changes in forearm vascular conductance) and measured indexes of left ventricular structure were not altered in either ET or UT, although peak transmitral inflow velocity increased in ET (P < 0.05). These findings demonstrate that moderate exercise training results in an enhancement in the ability to reflexly adjust heart rate with spontaneous changes in arterial pressure within the operating range. This occurs independently of any changes in carotid-cardiac baroreflex function over the full response range in cardiopulmonary baroreflex function or in cardiac structure.

Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography.

Abnormalities of diastolic filling are increasingly recognized as a cause of symptoms and predictors of outcome in patients with most forms of heart disease. Noninvasive assessment of diastolic filling is possible in almost all patients, but accurate evaluation must relate echocardiographic Doppler measurements to the complex physiologic and hemodynamic factors responsible for normal and abnormal filling. This evaluation has been facilitated by recent correlation of Doppler measurement of mitral and pulmonary venous inflow with hemodynamic studies. These studies have confirmed that when a careful, integrated approach is taken, Doppler flow patterns can document a progressive pattern of abnormality in many conditions. Impaired left ventricular (LV) relaxation is seen early and is recognized by a decrease in early transmitral LV filling and an increased proportion of filling during atrial contraction. As abnormalities progress, increasing LV chamber stiffness and elevated left atrial pressure lead to a "pseudonormal" filling pattern that previously has caused considerable confusion. This can be unmasked by careful evaluation of pulmonary venous inflow and the use of the Valsalva maneuver. When marked diastolic abnormalities are present, LV filling has restrictive features characterized by rapid early filling, a very stiff left ventricle with high filling pressures, and a poor prognosis. Routine measurement of indexes of diastolic filling have been hampered by uncertainty as to what should be measured, what techniques should be used, definition of normal values, and a clear method of reporting findings. This report represents the efforts of a Canadian consensus group to define a national standard for the performance and reporting of echocardiographic Doppler studies of diastolic filling.

Early neonatal death due to an unusual pattern of total anomalous pulmonary venous drainage.

Total anomalous pulmonary venous drainage (TAPVD) is an uncommon congenital cardiovascular anomaly caused by failure of the common pulmonary vein to develop a connection with the common atrium in early ontogeny, resulting in persisting connections between pulmonary and systemic venous systems and a left-to-right shunt. This usually occurs via a single, enlarged, well-defined venous channel. The authors present an unusual case of TAPVD with venous obstruction with a profusely arborizing plexus of veins arising from the common pulmonary vein and forming multiple tiny anastomoses with the systemic venous system. This plexus may represent the persistence of an earlier, less involuted embryological form of the primitive pulmonary splanchnic plexus than those found in previously described patterns of TAPVD.

Aortic ring abscess and mitral valve aneurysm in aortic valvular endocarditis: enhanced diagnosis with transesophageal echocardiography.

Aortic ring abscess and mitral valve aneurysms complicating infective endocarditis have previously been described as surgical or autopsy findings. More recently, transesophageal echocardiography has been shown to be more sensitive than standard transthoracic echocardiography or other imaging modalities in detecting each of these complications. Since aortic ring abscess and mitral valve aneurysms virtually mandate surgical intervention, their early detection may be crucial. This report describes a 35-year-old male with congenitally abnormal aortic valve which became infected and in whom both an aortic ring abscess and mitral valve aneurysm occurred. These findings are discussed and the pertinent literature is reviewed.

Change in atrial volume following restoration of sinus rhythm in patients with atrial fibrillation: a prospective echocardiographic study.

OBJECTIVES: To determine if restoration of sinus rhythm in patients with atrial fibrillation decreases atrial size, 16 patients undergoing elective cardioversion were prospectively studied. The frequent coexistence of atrial fibrillation and atrial dilation is well recognized. Recent data have demonstrated that atrial enlargement may be the result, rather than the cause, of atrial fibrillation. DESIGN: Echocardiographic examinations were performed before cardioversion, and at 24 h, three and six months of follow-up. Atrial dimensions were assessed in multiple orthogonal imaging planes and atrial volume was calculated using an ellipsoid formula. SETTING: A tertiary care university teaching hospital. PATIENTS: All patients admitted to hospital between June 1989 and June 1990 for elective cardioversion were considered for enrollment. Informed consent was obtained in all cases. Patients were excluded if echocardiographic images were technically inadequate or reversion to normal sinus rhythm was not achieved. Twenty-five patients were considered for inclusion. The final study population consisted of 16 patients. Complete follow-up data were obtained in 10 cases. MAIN RESULTS: Conversion to sinus rhythm resulted in a decrease in mean left atrial volume from 38.5 cm3 to 34.2 cm3 (P < 0.01) at 24 h, 21.7 cm3 (P < 0.02) at three months and 19.6 cm3 (P < 0.02) at six months. Mean right atrial volume decreased from 33.4 cm3 to 29.4 cm3 (P < 0.01) at 24 h, 19.1 cm3 (P < 0.02) at three months and 16.3 cm3 (P < 0.02) at six months of follow-up. CONCLUSIONS: Conversion from atrial fibrillation to sinus rhythm results in a significant decrease in both left and right atrial volumes.

Anterior wall myocardial infarction in a 15-year-old diabetic female associated with spontaneously resolving coronary thrombosis.

Myocardial infarction is an uncommon event in childhood and adolescence, and only rarely is found to be due to atherosclerotic disease. This report describes a 15-year-old diabetic female with an acute anterior wall myocardial infarction in whom initial coronary angiography showed a thrombus of the proximal anterior descending coronary artery which had resolved spontaneously by the time a follow-up study was carried out six weeks later. None of the usual precipitating causes of myocardial infarction in childhood were found, and repeat angiography did not demonstrate any fixed coronary artery disease. The relevant literature is reviewed and it is speculated that endothelial dysfunction, coronary spasm and altered coagulability may have contributed to the formation of intraluminal thrombus and subsequent infarction in this patient.

Cardiac tamponade secondary to haemophilus pericarditis: a case report.

Pyogenic pericarditis is encountered uncommonly in clinical practice. The majority of cases of clinically apparent pericarditis are viral in origin. When bacterial infection of the pericardial space does occur the causative organism is usually Staphylococcus or Streptococcus species. Isolation of an haemophilus organism from the pericardial space in this condition is distinctly unusual. There are only 10 previously reported cases in the literature of pericarditis secondary to Haemophilus influenzae. This report describes the case of a 36-year-old woman who presented with haemophilus empyema and purulent pericarditis progressing to cardiac tamponade. There are isolated reports of successful treatment of pyogenic pericarditis with closed drainage and antibiotics. In the absence of clear evidence demonstrating the efficacy of this approach the authors favour open exploration of the pericardial space.

Aortic dissection and use of the nicotine patch: a case involving a temporal relationship.

A 33-year-old woman presented with chest and abdominal pain shortly after first and second applications of the nicotine patch. Type A aortic dissection was diagnosed and repaired. Pathological examination revealed cystic medial necrosis, subacute and acute dissection, with no evidence of chronic aortic insufficiency. The close temporal relationship between applications of the nicotine patch and onset of symptoms compatible with dissection followed by extension raises the possibility that the nicotine patch was implicated in, or precipitated, this woman's aortic dissection.

In vitro analysis of colour Doppler flow with the use of proximal isovelocity surface area: improved flow estimates using a nonhemispherical model.

OBJECTIVE: To examine the geometry of the proximal isovelocity surface area (PISA) envelope and its associated isotach, and to evaluate the accuracy of two models of calculating volumetric flow by using the PISA technique. DESIGN: A new model for determining isotach geometry from the PISA envelope was developed and tested in an in vitro simulation. SETTING: Echocardiography Laboratory, Hotel Dieu Hospital, Kingston, Ontario. MATERIALS AND METHODS: PISA envelopes were visualized using an in vitro flow simulator with a series of sharp-edged orifices (2.5 to 16 mm diameter) at a range of flow rates (10 to 110 mL/s). INTERVENTIONS: Flow calculations based on the traditional hemispherical geometric assumption for the isotach and the new model were made and compared with measured flow rates. MAIN RESULTS: The hemispherical model systematically and significantly underestimated flow. The nonhemispherical model, which requires measurement of both the height (a) and lateral width (2d) of the PISA envelope, provided improved estimates of flow. CONCLUSIONS: The nonhemispherical model provides a better estimate of flow through an orifice. Flow rate Q can be calculated directly from the size of the PISA envelope and the aliasing velocity (VA) by using the relationship Q = (3.14d2 + 5.97da + 1.37a2)VA or can be read from a nomogram.

Laboratory evaluation of a new long-acting 3-azinomethylrifamycin FCE 22250.

FCE 22250 (3-(N-piperidinomethylazino)methylrifamycin SV) is a member of the new class of 3-azinomethylrifamycins characterized by a long persistance in animals, a good oral absorption and a broad antibacterial spectrum including mycobacteria. In the experimental mice infection sustained by Mycobacterium tuberculosis H37Rv, FCE 22250 shows an efficacy 14 times higher than rifampicin and is still therapeutic when administered once every three weeks.

LM 427, a new spiropiperidylrifamycin: in vitro and in vivo studies.

The spiropiperidylrifamycin LM 427 (4-deoxo-3,4-[2-spiro-N-isobutyl-4-piperidyl]-(1H)-imidazo-(2,5-dihydro) rifamycin S) displays a broad spectrum of potent antibacterial activity in vitro. In vivo it is particularly effective in the therapy of experimental tubercular infections of mice. Three schedules of treatment were employed and the best results were obtained when intermittent administrations were used (ED50 of LM 427; 7 times lower than rifampicin). LM 427 is well distributed in tissues of mice and rats, with lung concentrations 10 to 20 times higher than plasma levels.

Biological activity of a new class of rifamycins. Spiro-piperidyl-rifamycins.

The biological properties of spiro-piperidyl-rifamycins, a new class of rifamycin antibiotics, are described. In these derivatives the positions 3 and 4 have been incorporated into an imidazolyl ring bearing a spiro-piperidyl group N substituted with linear and branched aliphatic chains. The in vitro antibacterial activity against Staphylococcus aureus and Mycobacterium tuberculosis increases with the number of the carbon atoms in the linera side chain, whereas the inhibitory effect on Escherichia coli is lowered. The antibacterial activity is only marginally affected by branching of the side chain. In vivo (experimental infections of mice) the optimal therapeutic activity against M. tuberculosis is shown by compounds bearing 3 approximately 5 carbon atoms as a linear or branched side chain; in comparison with rifampicin, the potency of these derivatives is 2 approximately 3 times higher. The finding is in a good agreement with the exceptional tissue tropism, which seems to be a favourable property of this group of derivatives.