Effects of unstable shoes on trunk muscle activity in patients with chronic low back pain.

INTRODUCTION: Unstable shoes were developed as a walking device to strengthen the lower extremity muscles and reduce joint loading. Many studies have reported increased muscle activity throughout the gait cycle in most of the lower limb muscles in healthy adults using these shoes. However, no previous studies have explored the effects of wearing unstable shoes on trunk muscle activity in patients with chronic low back pain (CLBP). Therefore, the aim of the present study was to compare the activity of selected trunk muscles in patients with CLBP during a gait test while walking wearing unstable shoes or conventional flat shoes (control). METHODS: Thirty-five CLBP patients (51.1 ±â€¯12.4 y; 26 ±â€¯3.8 kg/m2; 9.3 ±â€¯5.2 Roland Morris Disability Questionnaire score) were recruited from the Orthopedic Surgery Service at the Hospital to participate in this cross-sectional study. All the participants underwent gait analysis by simultaneously collecting surface electromyography (EMG) data from erector spinae (ES), rectus abdominis (RA), obliquus internus (OI), and obliquus externus (OE) muscles, while walking on a treadmill with flat control shoes or experimental unstable shoes. RESULTS: The results showed significantly higher %EMG activity in the ES (mean difference: 1.8%; 95% CI: 1.3-2.2), RA (mean difference: 1.5%; 95% CI: 0.3-2.7), and OI (mean difference: 1.5%; 95% CI: 0.2-2.8) in the unstable versus the flat-shoe condition, with a large effect size for the ES (Cohen's d = 1.27). CONCLUSIONS: Based on these findings, the use of unstable shoes may be implicated in promoting spine stability, particularly in improving neuromuscular control of the trunk muscles in CLBP treatment.

The effectiveness of a video-supported group-based Otago exercise programme on physical performance in community-dwelling older adults: a preliminary study.

OBJECTIVES: To evaluate the short-term effects of a video-supported group-based Otago exercise programme (OEP) on physical performance variables in independent community-dwelling older adults. DESIGN: Preliminary randomized controlled trial. SETTING: Local senior centre. PARTICIPANTS: Fifty-one adults aged 65 and older with no cognitive impairment. INTERVENTION: Participants were randomly allocated to the intervention group (IG) or to the control group (CG). During 4 months, IG participants performed the exercise routine. MEASUREMENTS: The primary outcome measure was the Timed 'Up-and-Go' test (TUG). Secondary outcome measurements included functional balance, one-leg balance, lower-limb function and aerobic endurance. All data were collected before and after intervention. RESULTS: TUG scores showed a significant reduction in the performance time in the IG compared to CG after intervention [IG 7.5 (2.0) vs CG 8.8 (1.9), mean difference -1.3seconds, 95% confidence interval (CI) of the difference -2.3 to -0.1; P=0.03]. Secondary outcomes also showed a significant improvement in the performance of the functional balance [IG 54.9 (2.5) vs CG 51.4 (5.3), mean difference 3.5 points, 95% CI 1.2 to 5.8; P=0.003], one-leg balance [IG 39.1 (21.6) vs CG 15.6 (12.1), mean difference 23.5seconds, 95% CI 13.3 to 33.7; P<0.001] and lower extremity strength [IG 8.7 (3.8) vs CG 10.9 (3.3), mean difference -2.2seconds, 95% CI -4.2 to -0.1; P=0.035] in the IG compared to CG. CONCLUSION: This study shows that, from a short-term perspective, a video-supported group-based OEP programme can significantly improve the levels of mobility, functional balance, one-leg balance and lower extremity strength in community-dwelling older adults. TRIAL REGISTRATION: ClincicalTrials.gov ID: NCT02218411.

Effect of Kinesio Taping on gastrocnemius activity and ankle range of movement during gait in healthy adults: A randomized controlled trial.

OBJECTIVE: To examine the effect of KT on gastrocnemius surface electromyography (SEMG) activity and ankle range of motion during walking in healthy subjects. DESIGN: Randomized controlled trial, with concealed allocation and assessor blinding. SETTING: University Biomechanics Laboratory. PARTICIPANTS: Thirty six healthy physiotherapy students were randomized to KT or control group. OUTCOME MEASURES: At baseline and immediately after 72 h with the tape in situ: amplitude of LG SEMG activity during the stance phase, duration of the LG activity, onset and offset times of LG activity, ankle plantar- and dorsiflexion peaks, and the cadence of gait. RESULTS: ANOVA revealed a significant time × intervention interaction effect across two variables: duration of LG activation, F(1, 33) = 4.71, p = .037, η = .015; and onset F(1, 33) = 7.92, p = .008, η = .037. KT group showed significantly shorter duration of the LG activity as compared with control, and similar results were observed when comparing the onset of LG activation. No statistically significant differences between both groups were noted in the rest of the outcomes. CONCLUSION: KT does significantly shorten the duration of the LG activity during gait when applied 72 h in healthy adults. However, this result was not accompanied by a significant reduction in the amplitude of LG SEMG activity.

Análisis de la función ventricular derecha en resonancia magnética cardíaca. Comparación de la cuantificación en los planos eje corto y 4 cámaras / Cardiac magnetic resonance analysis of right ventricular function: comparison of quantification in the short-axis and 4-chamber planes

Objetivo. Comparar los métodos de segmentación del ventrículo derecho en los planos eje corto y 4 cámaras, en los estudios de resonancia magnética cardíaca, y realizar una correlación con el método ecocardiográfico tricuspid annular plane systolic excursion (TAPSE). Material y métodos. Se estudiaron 26 pacientes con diversas enfermedades cardiovasculares con un equipo de resonancia magnética de 1,5 T. Se adquirieron en todos los estudios imágenes en modo cine en eje corto y en 4 cámaras (steady-state free precession, 6 mm de grosor de corte, desde la base al ápex ventricular). En todos los pacientes se cuantificaron los volúmenes telediastólico, telesistólico y la fracción de eyección del ventrículo derecho. A 14 pacientes se les practicó también una ecocardiografía y se calculó la función ventricular derecha (TAPSE), el mismo día que se realizó el estudio de resonancia magnética cardíaca. Resultados. No hubo diferencias estadísticamente significativas en los volúmenes y la función del ventrículo derecho determinados con los 2 métodos de segmentación. La correlación al estimar los volúmenes fue excelente (r > 0,95) y disminuyó levemente para la fracción de eyección (r > 0,84). La correlación entre fracción de eyección del ventrículo derecho y TAPSE fue muy baja (r = 0,2; p < 0,01). Conclusión. Ambos métodos de segmentación ventricular cuantifican adecuadamente la función del ventrículo derecho. La correlación con el método ecocardiográfico es discreta (AU)

Objective. To compare the methods of right ventricle segmentation in the short-axis and 4-chamber planes in cardiac magnetic resonance imaging and to correlate the findings with those of the tricuspid annular plane systolic excursion (TAPSE) method in echocardiography. Material and methods. We used a 1.5 T MRI scanner to study 26 patients with diverse cardiovascular diseases. In all MRI studies, we obtained cine-mode images from the base to the apex in both the short-axis and 4-chamber planes using steady-state free precession sequences and 6 mm thick slices. In all patients, we quantified the end-diastolic volume, end-systolic volume, and the ejection fraction of the right ventricle. On the same day as the cardiac magnetic resonance imaging study, 14 patients also underwent echocardiography with TAPSE calculation of right ventricular function. Results. No statistically significant differences were found in the volumes and function of the right ventricle calculated using the 2 segmentation methods. The correlation between the volume estimations by the two segmentation methods was excellent (r = 0,95); the correlation for the ejection fraction was slightly lower (r = 0,8). The correlation between the cardiac magnetic resonance imaging estimate of right ventricular ejection fraction and TAPSE was very low (r = 0,2, P < .01). Conclusion. Both ventricular segmentation methods quantify right ventricular function adequately. The correlation with the echocardiographic method is low (AU)

Cardiac magnetic resonance analysis of right ventricular function: comparison of quantification in the short-axis and 4-chamber planes.

OBJECTIVE: To compare the methods of right ventricle segmentation in the short-axis and 4-chamber planes in cardiac magnetic resonance imaging and to correlate the findings with those of the tricuspid annular plane systolic excursion (TAPSE) method in echocardiography. MATERIAL AND METHODS: We used a 1.5T MRI scanner to study 26 patients with diverse cardiovascular diseases. In all MRI studies, we obtained cine-mode images from the base to the apex in both the short-axis and 4-chamber planes using steady-state free precession sequences and 6mm thick slices. In all patients, we quantified the end-diastolic volume, end-systolic volume, and the ejection fraction of the right ventricle. On the same day as the cardiac magnetic resonance imaging study, 14 patients also underwent echocardiography with TAPSE calculation of right ventricular function. RESULTS: No statistically significant differences were found in the volumes and function of the right ventricle calculated using the 2 segmentation methods. The correlation between the volume estimations by the two segmentation methods was excellent (r=0,95); the correlation for the ejection fraction was slightly lower (r=0,8). The correlation between the cardiac magnetic resonance imaging estimate of right ventricular ejection fraction and TAPSE was very low (r=0,2, P<.01). CONCLUSION: Both ventricular segmentation methods quantify right ventricular function adequately. The correlation with the echocardiographic method is low.

Effects of three different low-intensity exercise interventions on physical performance, muscle CSA and activities of daily living: a randomized controlled trial.

OBJECTIVES: To evaluate the short-term effects of three different resistance training programs, conducted at low intensity, on physical performance, muscle cross-sectional area (CSA) and the capacity to perform daily tasks in older adults living in a geriatric nursing home. DESIGN: Randomized controlled trial, with a 4-month intervention period. SETTING: A geriatric nursing home in Valencia, Spain. PARTICIPANTS: Eighty-nine adults aged 75 to 96 who were independent in their daily activities. INTERVENTION: After a baseline assessment, the participants were randomly assigned to the control group or one of the three intervention groups: volitional contraction (VC; n=22), neuromuscular electrical stimulation (NMES; n=22), or neuromuscular electrical stimulation superimposed onto voluntary contractions (NMES+; n=22). The intervention focused on knee extension exercises and its intensity was set at 40% of one-repetition maximum (1RM). MEASUREMENTS: The primary outcome measure was mobility. Secondary outcomes were rectus femoris CSA, balance, aerobic endurance, upper-body strength and the capacity to perform daily tasks. All data were collected at baseline and after the 4-month intervention period. RESULTS: The two-way ANOVA analysis showed a significant group×time interaction effect for the mobility (P=.022), rectus femoris CSA (P=.001), and the capacity to perform daily tasks (P=.05). The within-group analysis found a more prominent effect in the NMES+ group. Significant improvements were seen in rectus femoris CSA and the capacity to perform daily tasks in all intervention groups. Mobility only improved in the NMES+ group (P=.026). CONCLUSION: From a short-term perspective, NMES+ exercise training, performed at low intensity, can improve physical performance, muscle CSA, and the capacity to perform daily activities, and to partially mitigate age-related consequences in older adults.

[Semiautomatic quantification of left and right ventricular function in cardiac magnetic resonance imaging: a preliminary study]. / Cuantificación semiautomática de la función ventricular izquierda y derecha en resonancia magnética cardíaca. Estudio preliminar.

OBJECTIVES: The aim of this study was to compare a semiautomatic segmentation method to quantify the function of both ventricles in magnetic resonance imaging (MRI) with the manual tracing method. MATERIAL AND METHODS: We examined 17 patients with diverse cardiovascular diseases on a 1.5 Tesla MRI unit (Magnetom Symphony Quantum; Siemens Medical Systems, Erlangen, Germany) using the following parameters: maximum gradient, 30 mT/m; and slew rate, 125 T/m/s. In all studies, we acquired images in cine mode in the short axis (SSFP, 6mm slice thickness, from the base to the ventricular apex) with breath holding. To reduce the user interaction, we used only one image per patient to initiate the semiautomatic method. The semiautomatic method was based on a specifically designed algorithm of regional growth and border detection. We quantified the end-diastolic volume (EDV), end-systolic volume (ESV), and the ejection fraction (EF) for both ventricles in all patients. RESULTS: No significant differences between the two segmentation techniques were found in the quantification of either ventricle (p>0.05). The difference in the volumes, although nearly significant, are clinically irrelevant. The correlation for the estimation of left ventricular function was excellent (r>0.9), and the correlation for the estimation of right ventricular function was good (r>0.7). CONCLUSIONS: Our semiautomatic segmentation method enables the function of both ventricles to be quantified as accurately as the conventional method.

Pain relief by applying transcutaneous electrical nerve stimulation (TENS) during unsedated colonoscopy: a randomized double-blind placebo-controlled trial.

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative to traditional pain treatments. TENS has been studied in the past as a pain reduction modality in colonoscopy with limited success. Reviews and meta-analysis have shown that the inconclusive results of TENS may be due to the lack of randomized controlled trials and the difficulty in defining precise output parameters. The objective of this double-blind randomized placebo-controlled trial was to investigate the pain-relieving effect of a new application of TENS in unsedated screening colonoscopy. Ninety patients undergoing unsedated screening colonoscopy were randomly allocated to one of three groups: a control group (n=30), a group to receive active TENS (n=30), or a group to receive placebo TENS (n=30). A visual analogue scale (VAS) and a five-point Likert scale were used to assess pain 5 min into the procedure and at the end of the procedure. The patient's bloating sensation during colonoscopy and the effect on the duration of the procedure were also evaluated. Throughout the procedure, the active TENS group experienced a VAS pain score reduction ≥50% compared to the placebo TENS group (P<0.001) and the control group (P<0.001). On the five-point Likert scale, there was also a significant reduction in pain score in the active TENS group compared to the placebo TENS and control groups (P=0.009). No significant differences were found between the study groups as to the bloating sensation and the duration of the procedure. We conclude that TENS can be used as a pain relief therapy in unsedated screening colonoscopy.

Programación y aplicación de la estimulación nerviosa eléctrica transcutánea (TENS): guía de práctica clínica basada en la evidencia / Programming and application of TENS technique: Evidence-based clinical practice guidelines

ObjetivoDeterminar cuál de las múltiples posibilidades de programación y aplicación del TENS está más respaldada por la evidencia, de forma que pueda servir de guía en la práctica clínica.Estrategia de búsquedaIdentificación de estudios a través de diferentes bases de datos.Selección de estudios y datosSe incluyeron aquellos estudios sobre las variables de programación y aplicación del TENS, publicados en revistas o congresos científicos.Síntesis de resultadosSe localizaron 94 referencias. En general existe consenso respecto a la importancia de la correcta elección de los parámetros de programación del TENS y de la colocación de electrodos.ConclusionesLa aplicación recomendada de TENS derivada de la literatura hasta el momento sería: forma de impulso bifásica compensada simétrica, duración del impulso mayor a 250μs, alta frecuencia modulada, electrodos grandes situados directamente o sobre los dermatomas correspondientes al dolor, intensidad máxima, sin producir dolor (AU)

ObjectiveTo determine which of the many possibilities for programming and application of TENS is most supported by the evidence, so that it can be used as a guideline in the clinical practice.Search strategyIdentification of studies using different databases.Study and data selectionThose studies on the variables of programming and application of TENS, published in journals and scientific conferences, were included.Synthesis of the resultsWe found 94 references. In general, there is consensus on the importance of the correct selection of programming parameters and electrode placement of TENS.ConclusionsThe recommended application of TEN derived from the literature up to the present date would be: a balanced symmetrical biphasic pulse, pulse length greater than 250μs, modulated high frequency, and large electrodes, placed directly on the pain or over the dermatomes corresponding to the area of pain, maximum intensity without pain (AU)

¿Qué respuesta fisiológica desencadena la aplicación de la técnica de estimulación nerviosa eléctrica transcutánea? / Which physiological response triggers the application of the transcutaneous electrical nerve stimulation technique?

Objetivo. Revisar qué efectos fisiológicos tiene la aplicación de la técnica de estimulación nerviosa eléctrica transcutánea (TENS) sobre los pacientes, de modo que pueda servir de orientación para su correcta aplicación en la práctica clínica. La técnica TENS consiste en la aplicación de corriente eléctrica pulsada, tradicionalmente empleada con finalidad analgésica. A la hora de su utilización, los diferentes parámetros de programación del TENS deben ajustarse teniendo en cuenta que las diferentes posibilidades de programación van a activar diferentes mecanismos fisiológicos. En los últimos tiempos, se han venido realizando importantes estudios con animales y en sujetos sanos, con el fin de dilucidar qué efectos fisiológicos son los que se producen en el organismo al aplicarse TENS. Material y métodos. Se llevó a cabo una revisión exhaustiva de la literatura científica publicada sobre la utilización de la técnica TENS y sus efectos fisiológicos. Los estudios relevantes fueron identificados a través de una búsqueda en las diversas bases de datos, así como de libros de referencia en la materia, procedentes de la Biblioteca de la Universidad CEU-Cardenal Herrera de Valencia. Resultados. Se localizaron 97 referencias que cumplieron con los criterios de inclusión. Conclusiones. El TENS produce su efecto analgésico por la activación de las aferencias de los tejidos profundos por estimulación de las fibras aferentes primarias de gran diámetro ABeta. Los mecanismos de acción fisiológicos del TENS de alta y baja frecuencia son distintos, aunque ambos se producen a nivel periférico, espinal y supraespinal, y se basan primordialmente en la activación de distintos receptores opioides. Con la combinación de parámetros adecuada, el TENS reduce el dolor desde el primer minuto de aplicación. Respecto a la duración del efecto analgésico tras una sesión de tratamiento, se ha demostrado la importancia de emplear intensidades elevadas para conseguir una mayor duración del efecto postsesión. La aplicación repetida diariamente de TENS con los mismos parámetros produce el desarrollo de tolerancia. Aunque se ha especulado respecto a un efecto vascular de la aplicación de TENS, éste sólo tiene efecto sobre la circulación periférica aplicado a una intensidad suficiente para conseguir contracciones musculares importantes; en todo caso, el efecto es local sobre la zona de aplicación. La aplicación de TENS puede influir positivamente en la actividad muscular de pacientes con déficits motores en accidentes cerebrovasculares y otros desórdenes neurológicos (AU)

Purpose. To analyze the physiological effects of the application of the transcutaneous electrical nerve stimulation (TENS) technique on patients, to provide guidance for successful implementation in clinical practice. TENS technique involves the application of a pulsed electric current, traditionally used for pain control. Different TENS programming parameters should be adjusted, taking into account that the different programming options will activate various physiological mechanisms. Extensive studies in animals and in healthy subjects have been conducted recently, in order to elucidate the physiological effects produced in the body when TENS is applied. Material and methods. We conducted a comprehensive review of published scientific literature on the use of the TENS technique and its physiological effects. Relevant trials were identified through a search of various databases and reference books on the subject, from the Library of the CEU-Cardenal Herrera University of Valencia. Results. We found 97 references that met the inclusion criteria. Conclusions. TENS produces its analgesic effect by activation of afferents of deep tissues by stimulation of primary ABeta large diameter afferent fibers. The physiological mechanisms of action of TENS at low and high frequency are different, although both occur at peripheral, spinal and supraspinal level, and are based primarily on the activation of different opioid receptors. With the proper combination of parameters, TENS reduces pain from the first minute of application. Regarding the duration of analgesic effect after a treatment session, it is known the importance of using higher intensities for greater duration of post-session effect. The daily repeated application of TENS with the same parameters will lead to the development of tolerance. Although there has been speculation about a vascular effect of the application of TENS, it only has an effect on peripheral circulation when applied at intensity sufficient to achieve significant muscle contractions; in any case the effect is reduced in the area of application. The application of TENS can positively influence muscle activity in patients with motor deficits in stroke and other neurological disorders (AU)

Estudio del marco de referencia bioético en estudiantes españoles de Fisioterapia / Study of the bioethics framework of Spanish physiotherapy students

Objetivo: Determinar el marco de referencia antropológico y moral general de los estudiantes de Fisioterapia de una universidad española. De los resultados obtenidos se pretende colegir claves para modificar/potenciar los contenidos docentes que se les impartirán a lo largo de los años de formación.MétodoCon la base de un cuestionario sobre valores y ética, ya validado y estadísticamente significativo, se ha realizado una encuesta a 124 estudiantes españoles de la titulación de Fisioterapia.ResultadosSe realizó la comparación de medias mediante el contraste de hipótesis, utilizando la prueba de la t de Student, tomando como nivel de significatividad el 95% (p<0,05), con el fin de hallar diferencias significativas en las respuestas entre hombres y mujeres. Los estudiantes de Fisioterapia presentan un sistema de valores morales generales centrado en el factor religioso, comparten la idea de que el ser humano posee una dignidad intrínseca y son mayoritariamente creyentes; a su vez, se inclinan por los conceptos de ayuda y bienestar de los pacientes por delante de la autonomía y de la justicia; el 81% de los estudiantes se plantea a menudo cuestiones de tipo existencial.ConclusionesAunque paradójicamente en España toda la educación en el ámbito sanitario ha estado tradicionalmente influida por el marco de referencia biomédico, la visión ética de los estudiantes españoles de Fisioterapia es claramente humanística (AU)

Objective: To determine the general anthropological and moral reference framework of the physiotherapy students of a Spanish university. Based on the results obtained, it is aimed to find the keys to modify/strengthen the teaching content of the student's curricula.MethodUsing a reliable and already validated questionnaire on values and ethics, a survey was made of 124 Spanish physiotherapy students.ResultsMeans comparison were made with the contrast of hypothesis, using the t test with a 95% (p<0.05) reliability in order to find the significant differences between the answers of the men and women. The physiotherapy students have a moral value system focused on the religious factor. They share the idea that the individual has an intrinsic dignity and most of them are believers while they tend to give priority to helping and providing well-being to the patients over their autonomy and equal rights in health care. A total of 81% of the students usually pose existential type questions.ConclusionsAlthough paradoxically in Spain, all the education of the health professional has been traditionally based on the biomedical frame of reference and the Spanish physiotherapy student's ethics view is clearly humanistic (AU)

[Automatic detection of pulmonary nodules on computed tomography: a preliminary study]. / Detección automática de nódulos pulmonares en tomografía computarizada.Un estudio preliminar.

OBJECTIVES: Recent years have seen growing interest in the development of algorithms for computer-assisted diagnosis (CAD) for the detection of pulmonary nodules on both plain-film radiographs and computed tomography (CT) studies. The purpose of CAD algorithms in this context is to alert radiologists to suspicious radioopacities that might represent cancer in the images. We are developing a CAD system for the detection of pulmonary nodules on helical CT images. MATERIAL AND METHODS: We collected cases of patients with pulmonary nodules examined with helical CT. A total of 64 nodules, including both calcified and noncalcified lesions, ranging from 3 to 30 mm in diameter were included in the study. Studies were acquired on one 4-slice and one 64-slice CT scanners. Three chest radiologists at two institutions interpreted the studies to determine whether pulmonary nodules were present. We calculated the sensitivity and the number of false positives per image to evaluate the CAD system. RESULTS: We have developed and evaluated an algorithm for the automatic detection of pulmonary nodules on CT images. For a sensitivity of 76%, the false-positive rate was 1.3 per image. CONCLUSIONS: Our preliminary results suggest that the system might be useful for radiologists in the detection of pulmonary nodules on helical CT images.

Adverse effects of mammalian target of rapamycin inhibitors during the postoperative period after cardiac transplantation.

INTRODUCTION: Safety of treatment with mammalian target of rapamycin inhibitors (mTORi) in the postoperative period after heart transplantation (HT) is controversial. METHODS: We evaluated the incidence of postoperative complications (pericardial, pleural, and surgical wound complications) among nine de novo heart transplant recipients treated with mTORi compared with 19 patients who did not receive them during the same period (control group). RESULTS: No significant differences were observed between the two groups regarding sex, age, body mass index, pretransplant diagnosis, history of diabetes mellitus, prior cardiac surgery, or baseline renal function. The main laboratory parameters at 1 month were also similar. During the first 2 months after HT, four patients (44%) in the mTORi group developed severe pericardial effusions requiring drainage, compared to 1 (5%) in the control group (P = .026). All patients presenting this complication in the mTORi group received everolimus. In addition, two cases of sternal dehiscence were observed in the mTORi group, compared to none in the control group (P = .09); one patient on everolimus required sternal reopening and debridement for clinically suspected mediastinitis. Duration of chest tube drainage, quantity of collected pleural fluid, and need for thoracentesis were similar in both groups. CONCLUSIONS: In our series, patients receiving mTORi-particularly everolimus-during the postoperative period after HT showed a higher incidence of severe pericardial effusion requiring drainage, as well as a trend toward a higher incidence of sternal dehiscence, as compared to a group not receiving mTORi. The use of mTORi during the early postcardiac transplant period should be individualized.

Reversal of cardiac cirrhosis following orthotopic heart transplantation.

Irreversible hepatic cirrhosis greatly increases the risks attending heart transplantation (HT), and is accordingly considered to be an absolute contraindication for HT unless combined heart and liver transplantation can be performed. It is now recognized that hepatic cirrhosis can undergo regression if the source of insult is removed, but no cases of post-HT regression of cirrhosis of cardiac origin have hitherto been reported. Here we report a case of cardiac cirrhosis that underwent complete regression following orthotopic HT, and we discuss the implications of this case.

Late steroid withdrawal after heart transplantation and incidence of acute rejection.

BACKGROUND: Steroid withdrawal (SW) after heart transplantation (HT) reduces steroid-associated side effects, although it can increase acute rejection episodes (ARE). Patient selection criteria for SW and the time elapsed after HT for this maneuver are controversial issues. The objective of this study was to assess the safety of late SW after HT with regard to the occurrence of ARE and to analyze risk factors resulting in a poor evolution. METHODS: We studied a cohort of 24 patients who underwent SW late after HT. All of them had gone at least 4 years without any ARE. Independent variables were time after HT, general recipient and donor data, risk factors for ARE, and immunosuppression. The dependent variables were occurrence of ARE (proven or not proven with endomyocardial biopsy) and time and severity of ARE. RESULTS: Among 24 HT patients including 96% men with an overall mean age of 57 years who underwent SW, the mean follow-up was 2.32 +/- 0.86 years. Six patients (25%) displayed an ARE >or=2R according to the International Society for Heart and Lung Transplantation (ISHLT) at 5 +/- 3 months after SW. There were no deaths. Time from the last rejection episode to SW was 6.6 +/- 2 years. All ARE were treated with steroid boluses (mean total dose 1583 +/- 1044 mg). Among the HT patients with ARE, 5 (85%) had never experienced ARE after HT. Upon long-term follow-up, there were 2 deaths: 1 sudden death at 30 months after SW and 1 due to allograft vasculopathy at 20 months post-SW. Currently 92% are New York Heart Association (NYHA) functional class I with a mean left ventricular ejection fraction of 67% +/- 10%. CONCLUSIONS: In our series of HT with late SW after HT (even among an HT population with a low risk of rejection), there was a 25% rate of ARE. This study did not allow us to identify risk factors for ARE after SW. We believe that based upon these observations SW should be implemented with caution.

Late noncardiac surgery in heart transplant patients.

OBJECTIVE: Because of improved long-term survival of heart transplants (HT), patients often need noncardiac surgery (NCS). Immunosuppression may increase the infection rate. Inadequate management may increase the risk of dysfunction or acute rejection episodes (ARE). Long-term outcomes of NCS and optimal immunosuppressive management in the perioperative period are not well known. The objective of this study was to analyze the incidence, morbidity, and mortality of late NCS after HT. METHODS: We retrospectively evaluated the incidence and type of late NCS as well as the risk factors for complications and the mortality among 207 HT patients. Immunosuppression and ARE rates were also analyzed. RESULTS: One hundred and sixteen late NCS (84.5% elective) were performed in 72 HT patients (34.8%). Interventions were: 35 urologic (30.2%), 29 abdominal (25%), 14 vascular (12.1%), 13 ENT (11.2%), 11 skin and soft tissue (9.5%), and 7 orthopedic (6%). Malignancy was the main indication for NCS (33.6%). Only 4 patients (5.6%) died preoperatively. Mortality was higher among emergent vs elective procedures (16.6% vs 1%; P = .012) and among patients with preoperative high vs middle/low risk (26.6% vs 0%). Postsurgical infection was the most frequent complication (6.9%). However, there were no relevant complications in 82.8% of HT patients. Hospitalization time was <15 days in two thirds of patients. Immunosuppression was modified in 33 patients (28.4%), especially when the surgical indication was neoplasia (P < .001). None of the patients with NCS displayed allograft dysfunction or an ARE. CONCLUSIONS: More than one-third of HT patients needed a late NCS. In our experience, elective surgical procedures with middle/low preoperative cardiovascular risk are safe. In this context, the risk of rejection was low when immunosuppression was carefully monitored to reduce the risk of infection.

Long-term results of heart transplant in recipients older and younger than 65 years: a comparative study of mortality, rejections, and neoplasia in a cohort of 445 patients.

BACKGROUND: Whether being older than 65 years should be considered an absolute counterindication to heart transplant (HT), as it is in some centers, is controversial. In our centre, patients older than 65 years are accepted for HT if they satisfy stringent conditions. The aim of this study was to examine whether heart recipients older than 65 years have a greater risk of rejection, neoplasia, or mortality than younger ones. METHODS: We studied 445 patients who underwent HT between April 1991 and December 2003, 42 of whom were older than 65 years and 403 who were 65 years or younger. The parameters evaluated were the cumulative incidences of neoplasias and rejections (ISHLT grade > or = 3A), and the survival rates 1 month, 1 year, and 5 years post-HT. RESULTS: The two groups had similar percentages of patients with at least one rejection episode (< or =65 years 56.9%, >65 years 51.3%; P > .05), and although there were proportionally almost twice as many tumors in the older group (14.2%) as in the younger (7.9%), this difference was not statistically significant either. Nor were there any significant differences in survival, the 1-month, 1-year, and 5-year rates being 87.8%, 82.1%, and 68.8%, respectively, in the younger group and 85.7%, 78.6%, and 73.4%, respectively, in the older. CONCLUSIONS: Among carefully selected patients aged more than 65 years, HT can be performed without incurring greater risk of rejection, malignancy, or death than is found among recipients younger than 65 years.

[Total arterial myocardial revascularization with both mammary arteries without extracorporeal circulation]. / Revascularización miocárdica arterial completa con ambas arterias mamarias sin circulación extracorpórea.

INTRODUCTION: Tector has described the off-pump total arterial revascularization technique, using multiple anastomosis with both internal thoracic arteries. To reduce surgical morbid-mortality, we have proposed the use of this technique without extracorporeal circulation. PATIENTS AND METHODS: From April, 1998 the off-pump <> technique was performed in 92 patients, 74 male (80%) and 18 female (20%), with a mean age of 64.9+/-8.1 years (42-78). Preoperative angiography demonstrated triple-vessel disease in 58 (63%) patients, and left main disease was present in 19 (20.5%) patients. Forty patients (43.5%) showed unstable angina, 24 patients (26%) significant peripheral vascular disease, and 26 (28%) diabetes mellitus. Both internal thoracic arteries were harvested using the skeletonization technique and were used like a <> graft. The flow in the graft was measured using a flowmeter, and in 24 (26%) patients by angiographic study. RESULTS: A total of 274 distal anastomoses were performed, 122 (44.6%) in the lateral or inferior wall, and 69 (25.2%) were sequential, with an average of 2.98 bypass/patient. In 59.8% of the patients a triple bypass was performed, 22% double bypass, 17% cuadruple bypass and 1 patient a quintuple bypass. During the initial six hours 64.9% of patients were extubated. Only one patient (1.1%) needed intraaortic ballon pumping and 3 (3.2%) inotropics during the postoperative course. Hospital mortality was 3 (3.2%) patients. Reoperation for bleeding was needed in just one patient (1.1%), and 78.3% of patients were not transfused. Mediastinitis occurred in 3 patients (3.2%). Postoperative stroke was not observed. At 7.7+/-2.8 months of mean follow-up all patients were free of symptoms and the global patency rate of 94%. CONCLUSIONS: Off-pump Tector technique appears to be safe, offering a complete arterial revascularization and showing a reduction of surgical morbidity.

[Practice guidelines of the Spanish Society of Cardiology. Cardiac and heart-lung transplants]. / Guías de actuación clínica de la Sociedad Española de Cardiología. Trasplante cardíaco y de corazón-pulmones.

Cardiac transplantation is the only therapy that is able to substantially modify the natural evolution of patients with severe heart failure, along with angiotensin converting enzyme inhibitors. Nevertheless, because of the limited number of donors, its impact is scarce compared to the magnitude of the problem. Up to the end of 1998, 48,541 orthotopic cardiac transplantations and about 2,510 heart and both lung transplantations have been registered throughout the world. In Spain 2,780 procedures have been performed in the last 15 years. The survival expectations for a transplanted patient is 75% after the first year and 60% the following 5 years. The average duration of the graft is 8 years and 6 months. Cardiac transplantation is indicated for young and middle-age patients with irreversible cardiac process in bad clinical condition, with no other possibility of medical or surgical management and with a limited life expectancy. The major debate when choosing this therapy appears with the critical patients, patients older than 65 years, and some patients with systemic diseases. The great demand of transplantation obliges the teams to enlarge the criteria for donors' acceptance. At the same time, the increase of the knowledge about the transmission of some infections, mainly viral, forces to review those criteria day-to-day. The use of different immunosuppressive strategies pursues the control of rejection. The most commonly used is the so-called triple therapy (cyclosporine-azathioprine and steroids). The use of antilymphocytic antibodies such as cytolytic induction treatment is not unanimously accepted. Some of the new immunosuppressive agents such as myphenolate-mofetil and tacrolimus seem to offer advantages mainly due to their greater potency. Since transplantation is a limited procedure, of which its practise has an effect on the whole health system of a country, a perfect planning and adequacy of the Centers is compulsory, as well as the setting-up of clear rules for the use of donors and priority of transplantation. Finally, the patient must be informed clearly and comprehensively at length of the risks, limitations and expectations of these complex procedures.