Exercise capacity in apparently healthy survivors of cancer.

AIMS: To evaluate cardiopulmonary exercise tolerance in a large cohort of apparently healthy paediatric cancer survivors in order to determine their participation in sporting activities. METHODS: A total of 84 young (<21 years) asymptomatic childhood cancer survivors, who had been exposed to anthracyclines (mean dose 212 mg/m2) and/or chest irradiation (median dose 2000 cGy), with normal left ventricular systolic function at rest (fractional shortening >29%), and 79 healthy controls were studied. Exercise testing was performed on a treadmill ergometer. Gas exchange analysis and derived variables were measured on a breath-by-breath basis. Pulmonary functional evaluation was performed before exercise. Echocardiographic evaluation at rest was performed within one month before the exercise test. RESULTS: There were no differences in exercise responses between patients and controls. In boys <13 years, mean VO2 max was slightly but significantly lower than in controls. This finding was thought to be a result of decreased physical fitness as all the other exercise parameters were similar to those in the controls. CONCLUSIONS: Results show that apparently healthy survivors of paediatric cancer can take part in dynamic sporting activities if they exhibit a normal response to cardiopulmonary exercise testing, while those that exhibit a reduced VO2 max should be re-evaluated after an aerobic training programme, and should undergo tailored dynamic physical activity if the VO2 max does not normalise.

Evidence-based medicine and headache patient management by general practitioners in Italy.

The study explores the awareness of technical terms used in evidence-based medicine (EBM) and manner of treating patients with migraine among a random sample of 500 general practitioners (GPs). A mailed questionnaire included questions on GPs' demographics and practice characteristics; awareness of EBM; sources of information about migraine and EBM; and patient's treatment behaviour. Only 27.2% of GPs agreed that clinical trials are needed to evaluate the efficacy of treatments and this awareness was higher in those who learned about migraine from scientific journals or continuing education courses and who attended courses on EBM. For two-thirds of GPs, disability is equivalent to illness diagnosis, and this behaviour was more prevalent in those who agreed that clinical trials are needed to evaluate the efficacy of preventive or curative treatments of migraine and that the clinical approach to migraine required an evaluation of clinical effectiveness, in those who treated a lower number of headache patients, who were older, and in those who did not use guidelines. The majority (93.1%) of GPs indicated that it is important to integrate clinical practice and the best available evidence, and this behaviour was significantly more frequent in those who agreed that the clinical approach to migraine required a clinical effectiveness evaluation, that clinical trials are needed to evaluate the efficacy of preventive or curative treatments of migraine, and in those who attended courses on EBM. Training and continuing educational programmes on EBM and guidelines on treatments of headache for GPs are strongly needed.

Transoesophageal atrial pacing combined with transthoracic two dimensional echocardiography: experience in patients operated on with arterial switch operation for transposition of the great arteries.

OBJECTIVE: To assess the feasibility, safety, and diagnostic accuracy of transoesophageal atrial pacing stress echocardiography (TAPSE) combined with two dimensional transthoracic echocardiography (TTE) for evaluation of coronary perfusion in patients undergoing arterial switch operation for transposition of the great arteries. DESIGN: TAPSE combined with TTE was performed at the end of cardiac catheterisation. An ischaemic response was defined as > 1.5 mm horizontal or downsloping ST segment depression or as a new or worsened wall motion abnormality. The results were compared with results of coronary angiography. SETTING: Tertiary referral centre for paediatric cardiology and cardiac surgery. PATIENTS: 25 patients, mean (SD) age 29.5 (19) months, mean (SD) weight 12.5 (3.4) kg. MAIN OUTCOME MEASURES: Target heart rate (200 beats/min) was attained in 22 of 25 (88%) patients. Electrocardiographic ischaemic changes occurred in 4 of 25 (16%) and wall motion abnormalities in 3 of 25 (12%). Coronary obstructions were found in 2 of 25 (8%) patients. RESULTS: The test was feasible in all patients, without clinical complications requiring treatment. Compared with coronary angiography, the test had a sensitivity and a specificity of 100% and 95%, respectively, for the echocardiographic stress, and of 100% and 91%, respectively, for the electrocardiographic stress. The negative predictive value was 100% for both the echocardiographic and the electrocardiographic stress tests. The positive predictive value was 66% for the echocardiographic stress and 50% for the electrocardiographic stress tests. CONCLUSIONS: In these patients TAPSE combined with TTE was feasible and safe and apparently an accurate diagnostic method for evaluation of coronary perfusion. Patients with a negative test may have a low likelihood of major coronary abnormalities and may not require coronary angiography.

Percutaneous transluminal angioplasty of the left internal thoracic artery graft: a case report of a child operated on for anomalous origin of the left coronary artery from the pulmonary artery.

We report a case of an 8-year-old girl operated on with left internal thoracic artery-coronary artery anastomosis for anomalous left coronary artery from the pulmonary artery, in whom an early stenosis of the graft was successfully treated by percutaneous transluminal angioplasty.

Evolution of left ventricular diseasein the fetus. Case report.

A fetal case is described that showed a rapid progression from the features of initial left ventricular fibroelastosis at 20 weeks of gestation to a more marked dilation at 22 weeks and finally to a hypoplastic left ventricle with aortic stenosis at 24 weeks of gestation. This case confirms the evolutive character of left ventricular disease during fetal life.

Myocardial ischaemia un-masked by transesophageal atrial pacing combined with two-dimensional transthoracic echocardiography in a pediatric patient: a case report.

We describe a case of a child operated on for an anomalous origin of the left coronary artery from the pulmonary artery and proximal hypoplasia of the anomalous coronary, in whom residual inducible myocardial ischaemia was detected by means of transesophageal atrial pacing combined with transthoracic echocardiography.

Interruption of the aortic arch, ventricular septal defect, aortic atresia and aortopulmonary fistulous communication.

Interruption of the aortic arch in association with aortic atresia is a rare condition. We report the second case in literature in which survival was provided by an aortopulmonary fistulous communication.

Lysis of a right atrial thrombus of more than a week's duration by high dose urokinase in a one-year-old child.

The case of a one-year-old child in whom a large catheter-related right atrial thrombus of more than a week's duration was dissolved by urokinase is presented. After one week of unsuccessful heparin treatment, urokinase, via a central venous catheter, was added at a dose of 1500 IU/kg/h. Urokinase was subsequently increased by 1000 U/kg/h every day up to a maximum of 4500 IU/kg/h on the basis of thrombus size reduction as assessed by daily cross-sectional echocardiography. One week later the thrombus was almost completely dissolved. No major bleeding occurred. Warfarin was given for the next three months and the international normalized ratio (INR) was maintanied between 2 and 3. At the end of warfarin treatment echocardiography was negative for right atrial thrombosis. This case suggests that local high dose urokinase therapy can be safely and successfully used to dissolve large right atrial thromboses of more than a week's duration.

Acute myocardial infarction and residual impairment of coronary perfusion: unusual complications of mitral endocarditis in a paediatric patient.

In children, acute myocardial infarction is a rare complication of infective endocarditis. Since it is usually fatal, few data on the patients who have survived are available. We report the case of a child with acute myocardial infarction and residual impairment of the coronary reserve, complicating a mitral endocarditis.

Remnant of the common pulmonary vein: usefulness of magnetic resonance imaging in improving diagnosis. A case report in a child.

Abnormal incorporation of the common pulmonary vein can result in a fibromuscular partition of the left atrium, often appearing as an elongated mass on transthoracic echocardiographic examination. Differentiation from an atrial thrombus or tumour may sometimes be difficult. We report a case of a young patient with a left atrial mass detected by ultrasound study and correctly diagnosed by magnetic resonance imaging as remnant of the common pulmonary vein.

The relation between supraventricular tachyarrhythmias and left ventricular dysfunction after acute myocardial infarction.

The clinical characteristics of supraventricular tachyarrhythmias (SVTA) and their relation to left ventricular dysfunction were assessed in 208 consecutive patients with recent myocardial infarction. Arrhythmias were quantified on hospital discharge by 24 hour electrocardiographic recording. All the variables were evaluated between the second and the fourth week after infarction. SVTA occurred in 113 (54%) patients: Supraventricular premature beats (SVPB) in 49 (24%), frequent or repetitive SVPB in 37 (18%), atrial or junctional tachycardia in 23 (11%), atrial flutter or fibrillation in 4 (2%). Most of these arrhythmias occurred in the absence of symptoms, and the most complex forms were always selflimiting. No relation was found among the presence of different forms of SVTA and sex, coronary risk factors, previous history of ischemic heart disease, type or site of acute myocardial infarction, NYHA functional class. Age, left atrial dimension (LAD), cardio-thoracic ratio (CTR) and left ventricular ejection fraction (LVEF) at rest differed significantly among three groups of patients: those without SVTA, those with SVPB less than 100 per hour and those with frequent-repetitive SVPB or atrial-junctional tachycardia. The more SVTA complexity, the worse LAD, CTR, LVEF and the higher the age. Multivariate discriminant analysis showed that CTR was directly and LVEF inversely related to the occurrence of SVPB less than 100 per hour, while the presence of frequent-repetitive SVPB or supraventricular tachycardia was closely related to increasing age, LAD, CTR and decreasing LVEF. Patients with atrial fibrillation always showed the worst values of LAD, CTR, LVEF and age. The results of the present study show that different types of SVTA occurring at discharge from hospital after myocardial infarction are clinically benign, but always suggestive of different degrees of left ventricular dysfunction.

Significance of abnormal blood pressure response during exercise-induced myocardial dysfunction after recent acute myocardial infarction.

The relation between exercise left ventricular ejection fraction and blood pressure (BP) responses after an acute myocardial infarction (AMI) was investigated. Twenty-eight to 37 days after an uncomplicated AMI, 224 consecutive patients underwent exercise radionuclide angiography in the 40 degrees semisupine position. In 180 patients (group A, 80%), BP increased more than 5 mm Hg every stage; in 44 patients, BP responses were abnormal; in 33 (group B, 15%), BP did not increase during 2 stages; in 11 (group C, 5%), it decreased more than 5 mm Hg after an initial increase. Ejection fraction did not differ significantly among the 3 groups at rest (51 +/- 13 in group A, 50 +/- 18 in group B, 47 +/- 13 in group C [difference not significant]) or at peak exercise (51 +/- 16% in group A, 46 +/- 19% in group B, and 43 +/- 16% in group C, [difference not significant]). Exercise-induced left ventricular failure or hemodynamic decompensation occurred in 22 patients. In these patients, ejection fraction at rest was 44 +/- 19% and decreased to 35 +/- 16% (p less than 0.05) with exercise. Only 9 of these patients (41%) had abnormal BP responses, with the other 13 (59%) showing a normal BP responses. The The 35 patients with abnormal BP responses in the absence of hemodynamic decompensation were asymptomatic, terminating exercise because of fatigue. The ejection fraction at rest and during exercise in these patients was similar to that in patients with normal BP responses.(ABSTRACT TRUNCATED AT 250 WORDS)

[Efficacy of propafenone in the treatment of ventricular hyperkinetic arrhythmias in subjects with a history of myocardial infarction]. / Efficacia del propafenone nel trattamento delle aritmie ipercinetiche ventricolari in soggetti con pregresso infarto miocardico.

A placebo-controlled single-blind study was performed to evaluate the efficacy of oral propafenone on stable potentially malignant ventricular tachyarrhythmias in 13 patients who had suffered a myocardial infarction two months or longer before the trial. All patients exhibited at a 24 hour Holter monitoring a minimum mean frequency of 10 ventricular premature depolarizations (VPDs) per hour and repetitive VPDs. Ventricular tachyarrhythmias characterization was obtained by means of multiple Holter monitorings and exercise stress testings. Propafenone was considered as effective when a well-defined quantitative and qualitative reduction of ventricular tachyarrhythmias was reached. After an initial placebo phase, patients received propafenone 450 mg or 900 mg daily. Acute effectiveness of propafenone was proved in 8 on 13 patients (62%) who showed a significative reduction of VPDs (89%, p less than 0.02) and a suppression of the most complex forms of ventricular tachyarrhythmic events. The efficacy of propafenone was confirmed, three months later, in each patient, side effects were infrequent, minimal and of no clinical consequence. Oral propafenone can be considered as an effective drug for reducing the level of potentially malignant ventricular tachyarrhythmias in patients with previous myocardial infarction.

[Normal behavior during the exercise test of the left ventricular ejection fraction determined by an angioscintigraphic method]. / Sul comportamento normale durante sforzo della frazione di eiezione ventricolare sinistra determinata con metodo angioscintigrafico.

UNLABELLED: The correct definition of left ventricular ejection fraction (LVEF) normal response to exercise is still debated. The lack of unanimous agreement firstly depends on the different normality criteria adopted in literature. In order to make ligh, we carefully reviewed several papers on this matter, and performed exercise radionuclide angiography (RNA), by multiple gated blood pool, in 2 different populations. I group: 39 normal subjects, selected on the basis of normal clinical examinations, ECG, X-ray film, exercise test, at rest LVEF greater than 50%: 20 males, mean age 43 +/- 13%. II group: 22 patients, abnormal from the clinical point of view, but elsewhere included in control groups: 13 males, mean age 54 +/- 9%. 14 of them refer only atypical chest pain, in 5 the sole abnormal finding is an exercise-induced ST depression greater than 1 mm, in 2 a left bundle branch block at rest, 1 patient suffers from X syndrome. Symptom limited exercise RNA was carried out by adopting a semi supine (40 degrees) cycloergometer, with a 25 watt initial workload and 25 watt subsequent increases every 3 minutes; count acquisition lasted 2 minutes, from the end of the 1st to the end of the 3rd, during each stage of the test. RESULTS: I group: constant LVEF increment during exercise in all subjects: mean LVEF at rest was 65 +/- 8%, at maximum workload 80 +/- 8%: mean increase was 15 +/- 7%.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical significance of supraventricular tachyarrhythmias after acute myocardial infarction.

160 survivors of acute myocardial infarction (AMI) were evaluated to assess the clinical significance of supraventricular tachyarrhythmias (SVTA) occurring at discharge from the hospital after the acute event. All the variables considered for the study were estimated before hospital discharge; arrhythmias were quantified with a 24 h Holter ECG monitoring system. SVTA occurred in 88 patients (55%). Single or repetitive supraventricular premature beats were found in 65 (41%), paroxysmal atrial or junctional tachycardias in 20 (12%), bouts of atrial flutter or fibrillation in 3 (2%). Bivariate statistical analysis showed no relationship between sex, previous cardiovascular history, type, and location of AMI and SVTA occurrence. A close positive relationship was found between age, left atrial dimension (LAD), cardio-thoracic ratio (CTR) and SVTA occurrence; an inverse relationship was found for left ventricular ejection fraction (LVEF). The presence of SVTA appeared significantly related to age above 55 years, to LAD greater than 40 mm, to LVEF less than 45%, to serum creatine kinase peak levels over 1400 U l-1 and to CTR over 0.49. Multivariate statistical analysis showed that five variables are important in discriminating patients suffering from SVTA: age, LAD, LVEF, left ventricular fractional shortening, and CTR. SVTA occurring at discharge from hospital after AMI are indicative of impaired left ventricular pump function.

Exercise radionuclide ventriculography after uncomplicated myocardial infarction: what could we gain from the analysis of LVEF throughout the whole test?

To assess the usefulness of a step by step evaluation of exercise left ventricular ejection fraction (LVEF), 219 consecutive patients with recent uncomplicated myocardial infarction and 30 normal subjects underwent a symptom-limited cycloergometer test followed by exercise radionuclide ventriculography (ExRNV). LVEF was monitored throughout the whole test. 49 patients underwent coronary arteriography for clinical reasons. 5 patterns of exercise LVEF could be observed: progressive increase: 55 patients (25%) and 27 normal subjects (90%); progressive decrease: 37 patients (17%); initial increase followed by significant decrease: 54 patients (25%); lack of initial modification and terminal decrease: 35 patients (16%); no modification: 38 patients (17%) and 3 normal subjects (10%). Grouping the patients in this fashion allowed us to increase the specificity of ExRNV from 70% to 100%, without loss of sensitivity (95%). As for the patients in subgroup C, 32/54 showed unequivocal ECG ischaemic changes, occurring simultaneously with LVEF decrease; in 33/54 LVEF dropped during the last workload; in 25/54 the last stage LVEF was equal to or higher than the basal LVEF. The statistical analysis showed that ischaemic ECG changes (P less than 0.0001), exercise-induced wall-motion abnormalities (P less than 0.0001), and the presence of multivessel coronary artery disease (P less than 0.0001) were significantly more frequent in patients showing patterns (b)-(d), which should be considered as ischaemic. Our method allowed the unequivocal identification of ischaemic patterns in LVEF during exercise, which might be missed if only its basal and final values are considered.