Comparison of Short vs Long Anti-rotation in Treating Trochanteric Fractures.

Introduction: A comparative evaluation of the surgical treatment and outcome of patients with pertrochanteric fractures treated with short versus long proximal femoral nail antirotation. Materials and methods: A retrospective review was conducted of patients with pertrochanteric fractures treated between January 2011 and June 2012. In all 80 patients were enrolled in the study, of which 40 were treated with short PFNA and the remaining with long PFNA. Comparative analyses of demographic data, peri-operative outcome and complications were carried out. Results: There was no significant difference noted in the two groups with regards to Arbeitsgemeinschaft fur Osteosynthesefragen (AO) fracture classification, time from injury to surgery, blood transfusion post surgery and hospital stay. The surgical duration for a short PFNA procedure was significantly less (58 minutes) when compared to that of a long PFNA (87 minutes). Similarly intra-operative blood loss was significantly higher in the long PFNA group as compared to the short PFNA. Conclusions: A relatively quicker surgical time of just under an hour , lesser blood loss and better learning curve with trainee surgeons make short PFNA a better implant choice in the treatment of pertrochanteric fractures.

A comparison of outcome scores in os calcis fractures.

BACKGROUND: Of over 20 different scoring systems to evaluate outcome following calcaneal fracture, the Maryland Foot Score has broad current acceptance. A general health survey, the Short Form 36 (SF 36) has also been used. AIMS: The study compared two scoring systems for assessing the outcome of open reduction and internal fixation of displaced intra-articular calcaneal fractures. METHODS: Over a four-year period, 31 displaced intra-articular calcaneal fractures were categorised by the Sanders classification and treated by open reduction and internal fixation. Outcome was assessed by the Maryland Foot Score and by the Short Form 36 (SF 36) general health questionnaire. RESULTS: Thirty-five per cent of fractures were Sanders class 2, 57% were class 3 and 8% were class 4. The average follow-up was 2.5 years (range 1-4 years). Using the Maryland Foot Score, seven fractures had an excellent result, 13 had a good result, six had a fair result and one was a failure. There was a correlation between pain (coefficient = 0.780, p < 0.001) and physical function (coefficient = 0.638, p < 0.001) with the appropriate sections of the SF 36. CONCLUSION: The Maryland Foot Score measures what it attempts to measure and therefore it has content validity for pain and physical function.

A study of the efficacy and safety of irbesartan in combination with conventional therapy, including ACE inhibitors, in heart failure. Irbesartan Heart Failure Group.

Because heart failure therapy with angiotensin-converting enzyme (ACE) inhibitors may not be optimal, owing to persistent levels of angiotensin II occurring through incomplete blockade and alternate pathways, the benefit of adding irbesartan, an angiotensin receptor antagonist, to conventional therapy, including ACE inhibitors, was examined. In this multicentre, randomised, double-blind, placebo-controlled study, 109 patients with heart failure (New York Heart Association functional class II and III) and left ventricular ejection fraction (LVEF) < or = 40% received stable doses of ACE inhibitors and diuretics before and throughout the study. Irbesartan was titrated as tolerated to 150 mg once daily in all patients. Exercise tolerance time (ETT), LVEF and clinical status were assessed at baseline and after 12 weeks. Compared with placebo, irbesartan in combination with conventional therapy, including ACE inhibitors, produced favourable trends in ETT and LVEF and was well tolerated in patients with mild to moderate heart failure.

Direct selective blockade of the vascular angiotensin II receptors in therapy for hypertension and severe congestive heart failure.

ACEIs are widely prescribed antihypertensives and have become the mainstay of therapy for severe CHF. Nevertheless, a focused AII-receptor blockade has compelling intellectual appeal and substantial clinical advantages over the ACEIs (no disruption of the prostaglandin and bradykinin biosystems). Identification and careful characterization of the AII receptors and the recent discovery of their antagonists has led to the extensive clinical investigation of selective AII-receptor blockers in both hypertension and severe CHF. Studies with the first orally active AII-receptor blocker, losartan, have demonstrated safe and effective control of elevated blood pressure and improvement of the abnormal hemodynamics typical of pronounced CHF. Several other oral AII-receptor blockers are currently being evaluated, and early results with these agents are encouraging.

Placebo-controlled evaluation of three doses of a controlled-onset, extended-release formulation of verapamil in the treatment of stable angina pectoris.

This double-blind, placebo-controlled, parallel-group, multicenter study was designed to evaluate the safety and efficacy of a new controlled-onset, extended-release formulation of verapamil hydrochloride called physiologic pattern release (PPR) verapamil. The study was conducted at 24 sites (13 United States, 5 Canada, 6 overseas; see Appendix). Following a 1- to 3-week single-blind placebo lead-in period, 278 patients with chronic stable angina pectoris (247 males, 31 females, mean age 60.8 years, range 32 to 78) were randomly assigned to 1 of 4 once-daily, fixed-dose treatment groups: verapamil 180, 360, or 540 mg, or placebo. PPR verapamil at all doses significantly increased (p < 0.05) time to moderate angina and symptom-limited exercise duration, and verapamil 360 mg significantly increased (p < 0.05) time to > or = 1 mm ST-segment depression, after 4 weeks of treatment when assessed 24 hour after the previous dose. Larger doses of verapamil were associated with proportionately greater improvements in exercise tolerance. Frequency of anginal attacks was also reduced by verapamil. The most frequently observed adverse events were dizziness, headache, constipation, and nausea. The incidence of constipation was high (20.9%) within the 540 mg treatment group. This verapamil formulation can be clinically titrated within a 180 to 540 mg dosing range, permitting effective once-daily administration for the treatment of chronic stable angina.

Amlodipine in chronic stable angina: results of a multicenter double-blind crossover trial.

The efficacy and safety of amlodipine, 10 mg, a new long-acting calcium antagonist, was compared with placebo in 103 patients with stable angina pectoris in a multicenter double-blind crossover study. The trial consisted of an initial 2-week single-blind placebo period followed by a first period of 4 weeks of double-blind therapy, which was followed by a 1 week washout period and then a second 4-week double-blind period after treatments were crossed over. Twenty-four-hour Holter electrocardiographic monitoring was carried out in 12 patients at three centers. In the first double-blind period amlodipine produced a significantly greater increase in symptom-limited exercise duration (amlodipine 478.5 to 520.6 vs placebo 484.6 to 485.2 seconds; change +8.8% vs +0.1%, respectively; p = 0.0004) and total work (amldipine 2426 to 2984 vs placebo 2505 to 2548 kilopondmeters; change +24% vs +1.7%, respectively; p = 0.0006) and a decrease in angina attack frequency (from 3 to 1 per week; p = 0.016) and nitroglycerin consumption (from 2 to 0.5 tablets/wk; p = 0.01) compared with placebo. Holter monitoring revealed significant reductions in numbers (amlodipine 4.65 to 2.22 vs placebo 1.84 to 1.54; change -52% vs +84%, respectively; p = 0.06), absolute total area (amlodipine 87.66 to 11.43 vs placebo 5.76 to 35.24; change -87% vs +513%, respectively; p = 0.02), and duration (amlodipine 12.29 to 2.95 vs 1.66 to 7.74 seconds; change -76% vs +367%, respectively; p = 0.008) of ST-segment depressions after treatment with amlodipine compared with placebo. After the treatments were crossed over changes continued to favor amlodipine.(ABSTRACT TRUNCATED AT 250 WORDS)

Losartan in heart failure. Hemodynamic effects and tolerability. Losartan Hemodynamic Study Group.

BACKGROUND: The aim of the present study was to assess the short- and long-term effects of multiple doses of the angiotensin II receptor antagonist losartan in heart failure. METHODS AND RESULTS: A multicenter, placebo-controlled, oral, multidose (2.5, 10, 25, and 50 mg losartan once daily) double-blind comparison in patients with symptomatic heart failure and impaired left ventricular function (ejection fraction < 40%). Invasive 24-hour hemodynamic assessment was performed after the first dose and after 12 weeks of treatment. Clinical status and tolerability of treatment with losartan over the 12-week period were also evaluated. One hundred fifty-four patients were enrolled, of which 134 met the protocol criterion of baseline pulmonary capillary wedge pressure > or = 13 mm Hg. During short-term administration, systemic vascular resistance (SVR) (largest reduction against placebo of 197 dyne.s-1.cm-5 at 4 hours) and blood pressure fell significantly with 50 mg, lesser decreases were seen with 25 mg, and no discernible effects were seen with 2.5 and 10 mg. After 12 weeks of treatment, similar effects were seen on SVR and blood pressure (maximal fall in SVR against placebo, 318 dyne.s-1.cm-5 at 5 hours with 50 mg). In addition, pulmonary capillary wedge pressure fell with 2.5, 25, and 50 mg (largest reduction against placebo of 6.3 mm Hg at 6 hours with 50 mg), cardiac index rose with 25 and 50 mg, and heart rate was lower with all active treatment groups. Active treatment was well tolerated, and excess cough was not reported. CONCLUSIONS: This study showed that oral losartan administered to patients with symptomatic heart failure resulted in beneficial hemodynamic effects with short-term administration, with additional beneficial hemodynamic effects seen after 12 weeks of therapy. Clear effects were seen with both 25 and 50 mg, with the greatest effect seen with 50 mg.

Amlodipine combined with beta blockade for chronic angina: results of a multicenter, placebo-controlled, randomized double-blind study.

Amlodipine, a potent long-acting dihydropyridine calcium antagonist, was compared with placebo in a parallel, randomized, double-blind study in 134 patients with chronic stable angina pectoris maintained on beta-adrenergic blocking agents. After a single-blind, two-week placebo period, patients were randomized to receive either amlodipine (2.5, 5, and 10 mg) or placebo once daily for four weeks. The effects of amlodipine on maximal exercise time, work, time to angina onset, and subjective indices including angina frequency, nitroglycerin tablet consumption, and patient and investigator ratings were assessed. Each dose of amlodipine produced increases in exercise time and calculated total work accomplished compared to baseline. Improvements at 5 and 10 mg were significantly greater than placebo which produced no significant change (p less than 0.05). Qualitative improvements in the severity of angina were produced by amlodipine at 5 and 10 mg daily assessed by patient-rating questionnaires (p less than 0.05). Reductions in angina frequency attacks per week and weekly nitroglycerin tablet consumption occurred but were not statistically significant when compared with placebo. Adverse effects observed during amlodipine treatment prompted discontinuation of treatment in only 2 out of 100 patients. Three patients discontinued treatment for reported lack of efficacy. No laboratory abnormalities prompted treatment discontinuation and minor side effects of dizziness, nausea, headache, and fatigue were observed infrequently. The results of this controlled, large-scale multicenter trial suggest that amlodipine significantly increased exercise capacity and was well tolerated when added to the antianginal regimen of patients remaining symptomatic while receiving beta-blocking agents.

A cooperative multicenter study of captopril in congestive heart failure: hemodynamic effects and long-term response.

The acute hemodynamic effects, long-term clinical efficacy, and safety of the oral angiotensin-converting enzyme inhibitor, captopril, were assessed in a multicenter cooperative study of 124 patients with heart failure resistant to digitalis and diuretics. The cardiac status of most patients was deteriorating prior to the study. Favorable acute hemodynamic effects consistently occurred with captopril. Maximal mean percentage increases in cardiac index, stroke index, and stroke work index were, respectively, 35%, 44%, and 34%. Systemic and pulmonary vascular resistances were each decreased by approximately 40%, as were the filling pressures of the right and left heart. Infusion of nitroprusside in some of the same patients to an end point of a pulmonary capillary wedge pressure of 12 to 18 mm Hg (equivalent to that after captopril) revealed no significant difference in the effect of either drug on the other hemodynamic parameters. Recatheterization after 8 weeks of captopril therapy revealed sustained hemodynamic changes. Significant and sustained improvements in clinical status were observed in most patients as measured by changes in New York Heart Association (NYHA) functional classification and exercise tolerance times. Seventy-nine percent of patients for whom there were adequate NYHA class data improved. Twenty percent remained unchanged and 1% deteriorated. Those patients who had both pretreatment and post-treatment exercise stress testing exhibited a highly significant mean increase in exercise tolerance times of 34% (317 +/- 32 seconds pretreatment to 425 +/- 34 seconds, final measurement). There was no evidence of tachyphylaxis over an 18-month period.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of combined nitroglycerin and dobutamine infusion in left ventricular dysfunction.

The immediate therapy of severe left ventricular (LV) failure after acute myocardial infarction (AMI) frequently requires simultaneous preload reduction, pump output augmentation, and maintenance of systemic blood pressure. Therefore the effects of intravenous nitroglycerin (NG) and dobutamine (DB) were evaluated in 12 patients with severe LV failure following AMI. Nitroglycerin achieved salutary lowering of abnormally elevated LV filling pressure (23 to 14 mm Hg, p less than 0.001) while DB markedly augmented LV pump function (cardiac index rose from 1.7 to 2.5 L/min/m2, p less than 0.005). Notably, the combined infusion of NG + DB simultaneously decreased preload (LV filling pressure 23 to 14 mm Hg, p less than 0.001) and markedly enhanced LV pump performance (cardiac index increased from 1.7 to 2.4 L/min/m2, p less than 0.001). Minor decline in mean systemic blood pressure with NG (72 to 66 mm Hg, p less than 0.05) was rapidly reversed by DB addition (69 mm Hg, p greater than 0.05). Both agents were well tolerated without clinical or ECG evidence of myocardial ischemia or dysrhythmias. Thus the principally venodilator effects of NG minimize systemic hypotension while salutary augmentation of cardiac function in AMI with LV failure is achieved by NG + DB.

Vasodilator therapy of severe congestive heart failure: the special importance of angiotensin-converting enzyme inhibition with captopril.

Successful ambulatory afterload reduction therapy of severe chronic congestive heart failure (CHF) required the extensive evaluation of hemodynamic effects of vasodilator agents, precise characterization of differential cardiocirculatory actions, and objective confirmation of extended salutary improvements of the heart failure state. This article describes results of a series of investigations with the angiotensin-converting enzyme (ACE) inhibitor captopril (CPT) in several patients with severe CHF. CPT causes predominant peripheral venodilation, resulting in marked decline in elevated left ventricular preload and modest augmentation of the depressed cardiac output. These hemodymanic effects of oral CPT are similar to the effects of nitroprusside and prazosin on increased ventricular preload, but the latter vasodilators cause greater rise in low cardiac pump output. Importantly, the beneficial cardiocirculatory action of oral CPT provided prolonged cardiac benefits with symptomatic improvements confirmed by objective enhancement in left ventricular function documented by cardiac catheterization, echocardiography, nuclear scintigraphy, and treadmill exercise. Thus, ACE inhibition with oral CPT successfully provides marked long-term augmentation of cardiac performance and clinical status in refractory CHF.

Comparative analysis of the hemodynamic actions of captopril and sodium nitroprusside in severe chronic congestive heart failure.

The hemodynamic actions of the systemic vasodilators parenteral sodium nitroprusside (NP) and oral captopril (CPT) were compared in 11 patients with severe chronic congestive heart failure (CHF). While two agents produced similar reductions in mean blood pressure (NP, 90 to 70 mm Hg vs CPT, 88 to 74 mm Hg, p greater than 0.05) and left ventricular (LV) filling pressure (NP, 27 to 14 mm Hg vs CPT, 24 to 15 mm Hg, p greater than 0.05), they produce disparate effects on LV pump performance. NP raised cardiac index 35% (2.0 to 2.7 L/min/m2, p less than 0.005), whereas CPT increased this index 16% (1.9 to 2.2 L/min/m2, p less than 0.001). Concomitantly, the 31% elevation of stroke index produced by NP (26 to 34 ml/beat/m2, p less than 0.001) was greater (p less than 0.05) than the 15% rise produced by CPT (26 to 30 ml/beat/m2, p less than 0.001). Simultaneously, stroke work index showed similarly greater augmentation, and total systemic vascular resistance declined more with NP. These findings suggest that oral CPT is a predominant ventricular preload-lowering agent primarily likely to improve dyspnea related to severe pulmonary congestion in patients with advanced chronic CHF.

Complementary combined captopril and terbutaline therapy in severe chronic congestive heart failure.

The hemodynamic effects of captopril (CPT) alone and in combination with the beta-adrenergic receptor agonist terbutaline (TBT) were evaluated in 10 patients with severe chronic congestive heart failure (CHF). The heart rate remained unchanged, while CPT lowered mean systemic blood pressure from 86 to 64 mm Hg (p less than 0.001) and decreased left ventricular filling pressure markedly from 27 to 19 mm Hg (p less than 0.001). The addition of TBT produced no further change in these variables (p greater than 0.05). Simultaneously, CPT augmented cardiac index (CI) from 2.1 to 2.9 L/min/m2 (p less than 0.001) and stroke index (SI) from 27 to 37 ml/beat/m2 (p less than 0.001). Concomitant CPT-TBT further raised CI to 3.2 L/min/m2 and SI to 40 ml/beat/m2 (both less than 0.001). Further, the CPT-effected decline in total systemic vascular resistance from 1577 to 841 dynes . sec . cm-5 (p less than 0.001) was not reduced additionally by CPT-TBT combination (p greater than 0.05). These results indicate than both CPT and TBT markedly augment cardiac function in CHF. Moreover, the salutary effects of the systemic vasodilator appear additive to the beneficial actions of the beta-adrenergic receptor agonist, thereby providing substantial augmentation of the function of the failing heart.

Long-term hemodynamic and clinical efficacy of captopril therapy in ambulatory management of severe chronic congestive heart failure.

The 6-month extended vasodilator efficacy of the oral angiotensin converting enzyme (ACE) inhibitor, captopril (CPT), was evaluated by sequential cardiac catheterization, nuclear scintigraphy, echocardiography, treadmill exercise, and symptomatology in nine patients with severe chronic left ventricular (LV) failure (CHF). CPT lowered LV filling pressure (from 23 to 14 mm Hg acutely (p less than 0.001) and to 14 mm Hg (p less than 0.01) with continuous 6-month therapy; concomitantly CPT raised cardiac index from 2.03 to 2.46 L/min/m2 initially (p less than 0.02) and to 2.33 L/min/m2 (p less than 0.02) at 6 months. Simultaneously CPT raised LV ejection fraction from 0.21 to 0.25 acutely (p less than 0.01) and to 0.30 (p less than 0.001) and to 60 mm (p less than 0.001) at 6 months. These beneficial actions of CPT on LV pump function raised treadmill exercise duration (from 339 to 426 seconds initially (p less than 0.05) and to 499 seconds (p less than 0.05) at 6 months, while considerably reducing CHF symptomatology (p less than 0.001). Thus ACE inhibition by CPT provides markedly beneficial sustained hemodynamic and clinical improvement in advanced LV failure without fluid accumulation or late vasodilator drug tolerance.