Prediction of reparability of meniscal tears in athletes using magnetic resonance.

Meniscal tears account for approximately 15% of all knee injuries and almost 25% of them require surgical procedures. Magnetic Resonance Imaging (MRI) is widely used for noninvasive assessment of the knee joint and is considered reliable and a powerful tool for the detection of soft tissue injuries of the knee. The aim of the study was to evaluate the sensitivity, specificity, and accuracy of magnetic resonance imaging (MRI) to predict the meniscal tears repair in sports practitioners. 104 incoming consecutive patients who underwent knee joint ligament reconstruction and/or arthroscopy for the treatment of meniscal injury at knee joint were imaged using a 1.5-T MRI scanner prior to arthroscopy. MRI images were evaluated for anterior cruciate ligament (ACL), articular cartilage, and meniscal injury. Images were correlated with arthroscopic findings, used as the gold standard. The sensitivity, specificity, and accuracy of MRI in predicting meniscal repair were 61.1%, 65.94%, and 64.58%, respectively. The agreement between MRI and arthroscopy yielded a kappa index of 0.236, indicating fair agreement. When the menisci were evaluated separately, 65.85% sensitivity, 45.45% specificity, and 54.16% accuracy were found for the medial meniscus, while 46.15%, 79.51%, and 75.0% for the lateral meniscus, respectively. The accuracy was 62.09% in whose patients that arthroscopy was performed up to 3 months after MRI and 67.18% in those that this time frame was more than 3 months before surgery. The 54 meniscal injuries occurred more frequently in the posterior horn; most injuries had a longitudinal pattern and were located in the red-red (vascular) zone. We suggest that magnetic resonance imaging is only moderately accurate for the prediction of meniscus reparability.

Tolerability and safety profile of sildenafil citrate (Viagra) in Latin American patient populations.

Safety data from 546 men with erectile dysfunction (ED) enrolled in three double-blind, placebo-controlled studies conducted in distinct regions of Latin America were pooled and analyzed. The most commonly reported adverse events of all causalities associated with sildenafil treatment were headache (19%), flushing (14%), dyspepsia (6%), and nasal congestion (4%), reflecting the inhibitory effects of sildenafil on cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5) in the peripheral vasculature, gastroesophageal sphincter, and nasal mucosa. Visual symptoms were reported in 5.5%, reflecting sildenafil's minor inhibitory effects on cGMP-specific PDE6 in the retina. These adverse events were generally transient and mild, and rarely resulted in discontinuation of sildenafil therapy. Thus, in this representative sample of Latin American men with ED, including those with concomitant stable cardiovascular disease, sildenafil treatment was well tolerated with an incident rate of adverse events similar to reports from other patient populations.

Cholesterol lowering with statins reduces exercise-induced myocardial ischemia in hypercholesterolemic patients with coronary artery disease.

Coronary flow reserve is mainly influenced by the combination of luminal stenosis and vascular dilation capacity. Thus, after statin treatment, the reduction of ischemic threshold in patients submitted to exercise testing could be intensely influenced by angiographic severity. In this study, we verify the effect of statin treatment on exercise-induced myocardial ischemia in hypercholesterolemic patients with a broad range of coronary angiographic severities. Patients with 2 consecutive positive exercise tests, coronary stenosis > or =70%, total cholesterol > or =300 mg/dl, and triglycerides < or =200 mg/dl were randomly assigned to a 16-week treatment period with either diet alone (n = 39) or diet plus statins (simavastatin, n = 31 and pravastatin, n = 10). Statin-treated patients had a significant variation in total cholesterol (-46% vs -2.7%; p <0.01), low-density lipoprotein cholesterol (-58% vs 0.8%; p <0.01), and high-density cholesterol (+28% vs -6%; p <0.05) in comparison with the diet-only group. After 16 weeks of treatment, 36 patients (92%) in the diet group still had positive exercise tests, whereas only 7 patients (15%) of the statin group had a positive test (p <0.01). The proportion of positive tests was significantly reduced in subgroups of patients with 1-, 2-, or 3-vessel disease. Regarding the severity of coronary stenosis, the proportion of positive tests was significantly reduced in patients with stenosis between 70% and 90% and in patients with stenosis > or =90%. Moreover, the proportion of positive tests tended to decrease to a greater extent in patients with mild coronary disease. In conclusion, cholesterol-lowering treatment with statins reduces exercise-induced myocardial ischemia in hypercholesterolemic patients with mild or severe epicardial coronary stenosis.

Pravastatin reduces myocardial lesions induced by acute inhibition of nitric oxide biosynthesis in normocholesterolemic rats.

Pravastatin is useful in restoring endothelium-dependent relaxation in hypercholesterolemic animals. A single intravenous bolus injection of N(omega)-nitro-L-arginine methyl ester (L-NAME), a non-specific inhibitor of NO synthase, causes myocardial necrosis and reduces coronary flow in rats. Since rats do not develop hypercholesterolemia and atherosclerosis, we have tested the hypothesis that pravastatin protects the heart from myocardial lesions induced by L-NAME in the absence of alterations in cholesterol levels and plaque formation. Male Wistar rats fed standard chow were divided into four groups: CONTROL (n=14) - rats that received tap water alone for 18 days; L-NAME (n=14) -- rats that received L-NAME (15 mg/kg, i.v.) on the 14th day of the study; PRAVASTATIN (n=11) -- rats that received pravastatin (6 mg/kg/day) in their drinking water for 18 days; PRAVASTATIN+L-NAME (n=12) -- rats that received pravastatin (6 mg/kg/day) and L-NAME (15 mg/kg, i.v.) as indicated in the preceding groups. At the end of 18 days, the rats were sacrificed and the hearts removed for stereological analysis by light microscopy. Plasma nitrate/nitrite and thromboxane B(2) concentrations were determined immediately before and after L-NAME administration. Pravastatin prevented the ischemic lesions induced by the acute inhibition of NO biosynthesis (the area of myocardial lesions in the L-NAME group was greater than in the Pravastatin+L-NAME group: 101.6 microm(2) vs. 1.2 microm(2), respectively; P<0.0001) and markedly increased the plasma nitrate/nitrate concentrations, even before L-NAME administration. There were no significant changes in the plasma thromboxane B(2) concentrations.

Etofibrate but not controlled-release niacin decreases LDL cholesterol and lipoprotein (a) in type IIb dyslipidemic subjects.

Etofibrate is a hybrid drug which combines niacin with clofibrate. After contact with plasma hydrolases, both constituents are gradually released in a controlled-release manner. In this study, we compared the effects of etofibrate and controlled-release niacin on lipid profile and plasma lipoprotein (a) (Lp(a)) levels of patients with triglyceride levels of 200 to 400 mg/dl, total cholesterol above 240 mg/dl and Lp(a) above 40 mg/dl. These patients were randomly assigned to a double-blind 16-week treatment period with etofibrate (500 mg twice daily, N = 14) or niacin (500 mg twice daily, N = 11). In both treatment groups total cholesterol, VLDL cholesterol and triglycerides were equally reduced and high-density lipoprotein cholesterol was increased. Etofibrate, but not niacin, reduced Lp(a) by 26% and low-density lipoprotein (LDL) cholesterol by 23%. The hybrid compound etofibrate produced a more effective reduction in plasma LDL cholesterol and Lp(a) levels than controlled-release niacin in type IIb dyslipidemic subjects.

Etofibrate but not controlled-release niacin decreases LDL cholesterol and lipoprotein (a) in type IIb dyslipidemic subjects

Etofibrate is a hybrid drug which combines niacin with clofibrate. After contact with plasma hydrolases, both constituents are gradually released in a controlled-release manner. In this study, we compared the effects of etofibrate and controlled-release niacin on lipid profile and plasma lipoprotein (a) (Lp(a)) levels of patients with triglyceride levels of 200 to 400 mg/dl, total cholesterol above 240 mg/dl and Lp(a) above 40 mg/dl. These patients were randomly assigned to a double-blind 16-week treatment period with etofibrate (500 mg twice daily, N = 14) or niacin (500 mg twice daily, N = 11). In both treatment groups total cholesterol, VLDL cholesterol and triglycerides were equally reduced and high-density lipoprotein cholesterol was increased. Etofibrate, but not niacin, reduced Lp(a) by 26 percent and low-density lipoprotein (LDL) cholesterol by 23 percent. The hybrid compound etofibrate produced a more effective reduction in plasma LDL cholesterol and Lp(a) levels than controlled-release niacin in type IIb dyslipidemic subjects

Effect of spironolactone on ventricular arrhythmias in congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy.

Epidemiologic studies have shown an important increase in the high mortality of patients with congestive heart failure (CHF) despite optimal medical management. Ventricular arrhythmia was recognized as the most common cause of death in this population. Electrolyte imbalance, myocardial fibrosis, left ventricular dysfunction, and inappropriate neurohumoral activation are presumed responsible for sudden cardiac death. In this study, we focused on the deleterious effects of the overproduction of aldosterone that occurs in patients with CHF. Secondary hyperaldersteronism can be part of several factors thought to be responsible for sudden cardiac death. We randomized 35 patients (32 men, aged 48 +/- 9 years) with systolic dysfunction (ejection fraction 33 +/- 5%) and New York Heart Association class III CHF secondary to dilated or ischemic cardiomyopathy into 2 groups. The treatment group received spironolactone, an aldosterone receptor antagonist, along with standard medical management using furosemide, angiotensin-converting enzyme inhibitors, and digoxin. The control group received only the standard medical treatment. Holter monitoring was used to assess the severity of ventricular arrhythmia. After 20 weeks, patients who received spironolactone had a reduced hourly frequency of ventricular premature complexes (VPCs) (65 +/- 18 VPCs/hour at week 0 and 17 +/- 9 VPCs/hour at week 16) and episodes of nonsustained ventricular tachycardia (VT) (3.0 +/- 0.8 episodes of VT/24-hour period at week 0, and 0.6 +/- 0.3 VT/24-hour period at week 16). During monitored treadmill exercise, a significant improvement in ventricular arrhythmia was found in the group receiving spironolactone (39 +/- 10 VPCs at week 0, and 6 +/- 2 VPCs at week 16). These findings suggest that aldosterone may contribute to the incidence of ventricular arrhythmia in patients with CHF, and spironolactone helps reduce this complication.

Additional reduction in blood pressure after cholesterol-lowering treatment by statins (lovastatin or pravastatin) in hypercholesterolemic patients using angiotensin-converting enzyme inhibitors (enalapril or lisinopril).

Blood pressure (BP) reduction was compared between patients receiving angiotensin-converting enzyme inhibitors alone and patients receiving these medications plus statins after 3 months of dietary intervention. Although BP was similarly reduced at week 4, the statin-treated group had a greater reduction in BP and total cholesterol levels at week 16, suggesting a synergistic effect between cholesterol lowering with statins and angiotensin-converting enzyme inhibitor treatment for hypertensive patients.

[High output heart failure due to coronary fistula]. / Insuficiência cardíaca de alto débito devida a fístula coronária.

A 45 year-old woman complaining of heart failure symptoms (New York Heart Association--class III) and a non typical thoracic pain was submitted to a transthoracic echocardiogram which showed a very dilated coronary artery and a fistula to the right atrium. The angiograms confirmed the same findings. She underwent open heart surgery which confirmed the diagnosis. Fistula ligation was then undertaken. She remains symptom-free three years after the operation.

Prevalence of the prothrombin gene variant 20210 G --> A among patients with myocardial infarction.

OBJECTIVE: The aim of this study was to determine the prevalence of the prothrombin variant allele 20210A among survivors of myocardial infarction. BACKGROUND: The prothrombin gene variant has been identified as a novel genetic risk factor for venous thrombosis. However, the risk of developing arterial thrombosis as a result of the presence of this mutated allele is unknown. METHODS: The G-->A transition at position 20210 of the 3'-untranslated region was determined in 220 survivors of myocardial infarction and in 295 individuals from the general population. RESULTS: The prevalence of heterozygotes for the prothrombin mutated allele was 3% among patients with myocardial infarction and 0.7% in the general population (P = 0.03). No age-related difference in the prevalence of the mutated allele was observed. However, for individuals over 45 years old the prevalence among females was higher than among males (5% vs. 0%). CONCLUSION: These data suggest that being heterozygote for the allele variant 20210A of the prothrombin gene could be a genetic risk factor for developing myocardial infarction.

Long-term antianginal and antiischemic effects of mibefradil, the novel T-type calcium channel blocker: a multicenter, double-blind, placebo-controlled, randomized comparison with sustained-release diltiazem.

This study compared the efficacy, safety, and tolerability of mibefradil to sustained-release diltiazem in patients with chronic stable angina pectoris. At week 12, statistically equivalent mean increases in exercise tolerance test (ETT) duration of > 1 minute were observed in both groups. Similar improvements in time to onset of angina and time to persistent 1 mm ST-segment depression were also observed with both drugs. Large reductions in heart rate, blood pressure, and rate-pressure product were observed at each stage of the ETT among patients treated with mibefradil. Each drug was associated with at least a 70% reduction from baseline in anginal frequency and nitroglycerin consumption. Patients maintained on mibefradil during the withdrawal period had significant increases in all three ETT variables at week 16 compared with placebo. The effectiveness of mibefradil is comparable with sustained-release diltiazem in treating chronic stable angina pectoris, although mibefradil provides greater reductions in heart rate and cardiac workload.

[Streptokinase in severe pulmonary thromboembolism]. / Estreptoquinase no Tromboembolismo Pulmonar Grave.

Severe pulmonary embolism (PE) was treated with streptokinase in four patients, three men and one woman, age 38 to 72 (mean = 53 +/- 14) years. Before the thrombolytic therapy, all patients had pulmonary angiogram and hemodynamic parameters analyzed. The drug was infused through the distal lumen of the Swan-Ganz catheter at the pulmonary artery trunk. The initial dosage was 250,000 units "in bolus" and 100,000 units in 24 to 72 hours. The time interval between the symptoms and treatment had ranged from 2 hours to 5 days. The results are analyzed as follow: reduction on right atrial pressure, mean pulmonary pressure, pulmonary vascular resistance, an increase in the stroke volume and cardiac output. In two cases we observed total lysis, in one partial lysis and one patient died from severe form of PE and late infusion of SK. Reinfusion of the drug was necessary in one patient that had PE recurrence with reliable final result. Finally, no one had severe bleeding despite the use of the intrapulmonary catheter.

Acute myocardial infarction in sickle cell anaemia associated with severe hypoxia.

A 17 year old boy with sickle cell anaemia presented with acute myocardial infarction associated with severe hypoxia and reticulocytopenia. Ischaemic heart disease is rare in sickle cell anemia and in this case it is possible that the acute episode of hypoxia led to myocardial infarction.