Left Ventricular Noncompaction: A Rare Cause of Effort Angina Unveiled During Left Heart Catheterization.

Effort angina is an under-appreciated presentation of left ventricular non-compaction that frequently leads to a late diagnosis. Cardiac ventriculography can assist in this diagnosis.

Impact of frailty on hospital adverse outcomes in elderly admitted with acute coronary syndrome

BACKGROUND: Frailty represents a complex clinical syndrome of decreased physiological reserve and increased vulnerability to stressors. Little is known regarding interaction between frailty status and outcomes in patients with acute coronary syndrome. Our study aims to assess the prevalence of frailty and its impact on in-hospital adverse outcomes of patients aged ≥ 75 years admitted for acute coronary syndromes. METHODS: In this retrospective, single centre, observational study were included patients aged ≥ 75 years admitted for acute coronary syndromes between January 2011 and December 2015. Frailty was assessed using the Fried criteria. The primary endpoint was all-cause in-hospital mortality. Secondary endpoints included the occurrence of re-infarction, stroke and major bleeding. RESULTS: Of the 502 patients included, 126 were classified as frail. These patients were older (mean age 78±5.5 vs. 76.2±5.5 years; p = 0.020), more often male (68.3%) and had a higher risk profile according to GRACE (151.4±18.8 vs. 132.1±16.8; p < 0.001), TIMI (4.3±1 vs. 3.1±1; p < 0.001) and CRUSADE (34.6±9.4 vs. 25.8±9.5; p < 0.001) scores at admission. All-cause in-hospital mortality was significantly more frequent in frail patients (11.9% vs. 5.6%; p < 0.001), as well as re-infarction (7.4% vs. 4.8%; p < 0.001), stroke (8.7% vs. 0.5%; p = 0.002) and major bleeding (7.9% vs. 1.6%; p = 0.002). On multivariate analysis, frailty remained independently associated with the primary endpoint (OR 5.63, [2.05-10.35]; p < 0.001). CONCLUSION: Frailty, identified by Fried criteria, is frequent in elderly patients with acute coronary syndromes, and it is an independent prognostic predictor for in-hospital mortality

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Musculoskeletal ultrasound in Paediatric Rheumatology: a retrospective analysis.

OBJECTIVES: Musculoskeletal Ultrasound (MSK-US) has become increasingly important in the diagnosis and follow-up of children with rheumatic diseases. We describe the experience of a large Portuguese centre and study the added value of MSK-US in the clinical assessment of paediatric rheumatic diseases. MATERIAL AND METHODS: Patients were observed by assistant Rheumatologists, a clinical diagnosis was assigned and MSK-US requested. 330 MSK-US exams were performed to 222 children with rheumatic inflammatory diseases. The children's ages were between 1 and 18 years (mean=11.7±4.7 years) and 67.6% were female. Synovial membrane proliferation, intra-articular effusion, cartilage abnormalities, erosions and periarticular affections were searched in each joint. Clinical and ultrasonography data were compared. RESULTS: MSK-US detected synovitis in 100 of 194 exams (51.5%) of patients with that clinical information and in 36 of 136 exams (26.5%) of patients who presented other clinical findings. In those in which MSK-US did not confirm the clinical information of synovitis (94; 48.5%), we detected tenosynovitis/tendinopathy in 13 cases (13.8%) and synovial cyst in four (4.3%). The remaining patients had no ultrasonography changes and MSK-US helped to exclude synovitis. The sensitivity for arthritis clinical assessment was good (73.5%), with modest specificity (51.5%), an accuracy of 60.6% and precision of 51.5%. Ultrasonography synovitis was mostly found in the knee (37.5%), followed by the ankle (22.8%) and hip (10.3%). Overall, 39 exams showed ultrasonographic tenosynovitis/tendinopathy, 15 of which had the same clinical diagnosis. Tenosynovitis/tendinopathy was mostly found in the ankle (59.0%) and knee (23.1%) areas. CONCLUSIONS: MSK-US is an important aid to clinical evaluation, allowing both the detection and exclusion of joint pathology in children, contributing to a better assessment.

Outbreak of Ochrobactrum anthropi endophthalmitis following cataract surgery.

Postoperative endophthalmitis often progresses to significant visual impairment. This paper describes an outbreak of Ochrobactrum anthropi endophthalmitis following cataract surgery, and propose a new sterilization protocol to minimize the risk of further cases. Medical records of patients with O. anthropi endophthalmitis or with suggestive clinical findings during the outbreak were reviewed. Seven cases of O. anthropi pseudophakic endophthalmitis were confirmed between 24 July and 10 November 2010. The most probable cause of the outbreak of Ochrobactrum anthropi endophthalmitis was contamination of the tubing of the phaco-emulsification machine. Following introduction of a new sterilization protocol, no further cases occurred in over 1000 subsequent procedures.

Complications of endomyocardial biopsy in heart transplant patients: a retrospective study of 2117 consecutive procedures.

BACKGROUND: Endomyocardial biopsy (EMB) remains the gold standard for the diagnosis of graft rejection after heart transplantation (HT). Our purpose was to evaluate the rate of complications of this invasive procedure. METHODS: This was a retrospective study of 175 patients, who were transplanted between November 2003 and October 2010 and survived more than 1 month after surgery. We evaluated the number of inconclusive EMB and described the incidence, nature, and subsequent management of several complications associated with this procedure. RESULTS: Over a period of approximately 7 years, we performed 2217 EMB yielding 4972 specimens, namely, an average of 2.3 fragments per procedure. The majority of EMBs (95.3%) were performed by the femoral approach. Only 12 EMB (0.57%) were inconclusive. The overall complication rate was 0.71%. During puncture, one patient experienced a vasovagal reaction and another one, a femoral artery false aneurysm. During the biopsy, there was one case of cardiac perforation with tamponade, two cases of supraventricular tachycardia, and three atrioventricular conduction abnormalities. In 19 patients, histological analysis revealed chordal tissue, but only two patients developed mild tricuspid regurgitation. We observed five cases of coronary artery fistulae. The clinical outcomes were favorable in all cases. CONCLUSION: EMB proved to be a suitable, safe method to monitor rejection after HT.

Comparative study of Botox injection treatment for upper eyelid retraction with 6-month follow-up in patients with thyroid eye disease in the congestive or fibrotic stage.

AIM: To compare morphometric data of the eyelid fissure and the levator muscle function (LF) before and up to 6 months after transcutaneous injection with five units of Botox in patients with upper lid retraction (ULR) from congestive or fibrotic thyroid eye disease (TED). METHODS: Twenty-four patients with ULR from TED were submitted to transcutaneous injection of 5 units (0.1 ml) of Botox in one eye only. Patients were divided into two groups: 12 with congestive-stage TED (CG), and 12 with fibrotic-stage TED (FG). Bilateral lid fissure measurements using digital imaging and computer-aided analysis were taken at baseline and at regular intervals 2 weeks, 1 month, 3 months and 6 months after unilateral Botox injection. Mean values taken at different follow-up points were compared for the two groups. RESULTS: Most patients experienced marked improvement in ULR, with a mean reduction of 3.81 mm in FG and 3.05 mm in CG. The upper eyelid margin reflex distance, fissure height and total area of exposed interpalpebral fissure were significantly smaller during 1 month in CG and during 3 months in FG. Reduction in LF and in the difference between lateral and medial lid fissure measurements was observed in both groups. The treatment lasted significantly longer in FG than in CG. CONCLUSIONS: A single 5-unit Botox injection improved ULR, reduced LF and produced an adequate lid contour in patients with congestive or fibrotic TED. The effect lasts longer in patients with fibrotic orbitopathy than in patients with congestive orbitopathy.

Resultados econômicos de sistemas de produção de leite com diferentes níveis tecnológicos na região de Lavras, MG / Economic results of milk production systems with different technological levels in the area of Lavras, Minas Gerais, Brazil

Estudou-se a rentabilidade da atividade leiteira na região de Lavras, MG, analisando a influência do nível tecnológico sobre o custo de produção do leite. Foram identificados os componentes com maior influência sobre os custos finais da atividade e calculado o ponto de equilíbrio. Os dados, provenientes de 16 sistemas de produção, representando os níveis tecnológicos baixo, médio e alto, foram coletados mensalmente, entre janeiro de 2002 e junho de 2003. Consideraram-se a margem bruta, a margem líquida e o resultado (lucro ou prejuízo) como indicadores de eficiência econômica. O nível tecnológico influenciou o custo total de produção do leite - lucratividade e rentabilidade. Os sistemas de produção com nível tecnológico baixo apresentaram o menor custo unitário. O nível tecnológico influenciou os itens componentes do custo operacional efetivo da atividade leiteira. A margem líquida positiva e a lucratividade negativa, nos três níveis tecnológicos, indicaram que os pecuaristas estarão se descapitalizando a longo prazo, mas não a médio prazo.

Inflammatory cell infiltrate and RANKL/OPG expression in rheumatoid synovium: comparison with other inflammatory arthropathies and correlation with outcome.

OBJECTIVES: To evaluate if the immunofluorescence analysis of synovial tissue (ST) using antibodies against RANKL/OPG, conjugated with the immunophenotyping of lymphocytes and macrophages, could be of diagnostic and prognostic value in rheumatoid arthritis (RA) patients. METHODS: 3-year prospective study of 103 consecutive patients submitted to closed needle biopsy for diagnostic purposes. ST was analyzed with routine histologic techniques and immunofluorescence, using monoclonal antibodies against RANKL, OPG, CD163, CD68, CD4, CD8, interferon-gamma and CD19. Patients were prospectively evaluated with a clinical, laboratorial and radiological protocol. At the end of the follow-up patients were divided according to the final diagnosis. Results of the initial histologic evaluation were compared between the main diagnostic groups and in RA patients histologic data was correlated with clinical and radiologic outcome measures. RESULTS: The RANKL/OPG ratio and the inflammatory infiltrate were significatively higher in RA (n = 25) as compared to the same ratio observed in other inflammatory joint diseases (OIJD, n = 48) and in osteoarthritis (n = 17). The difference between RA and OIJD was specifically confirmed when the comparison involved spondyloarthropathy (n = 26). Final HAQ score and radiologic outcome were correlated with the density of intimal CD68+ macrophages. Radiologic progression was correlated with subintimal CD4+ lymphocytes and CD68+ macrophages and intimal CD68 and CD163+ macrophages. CONCLUSION: The quantification of the RANKL/OPG ratio and of the number of lymphocytes in the ST might be useful to differentiate RA from other inflammatory joint diseases. The ST number of CD4+ lymphocytes and macrophages are probable predictors of radiologic progression in RA patients.

Gender-related differences in the effects of nitric oxide donors on neuroleptic-induced catalepsy in mice.

It has been suggested that nigrostriatal dopaminergic transmission is modulated by nitric oxide (NO). Since there is evidence that gonadal hormones can affect extrapyramidal motor behavior in mammals, we investigated the effects of isosorbide dinitrate (ISD), linsidomine (SIN-1) and S-nitroso-N-acetylpenicillamine (SNAP), three pharmacologically different NO donors, on neuroleptic-induced catalepsy in 60- to 80-day-old male and female albino mice. Catalepsy was induced with haloperidol (1 mg/kg, ip) and measured at 30-min intervals by means of a bar test. Drugs (or appropriate vehicle) were injected ip 30 min before haloperidol, with each animal being used only once. ISD (5, 20 and 50 mg/kg) caused a dose-dependent inhibition of catalepsy in male mice (maximal effect 120 min after haloperidol: 64% inhibition). In the females only at the highest dose of ISD was an attenuation of catalepsy observed, which was mild and short lasting. SIN-1 (10 and 50 mg/kg) did not significantly affect catalepsy in female mice, while a significant attenuation was observed in males at the dose of 50 mg/kg (maximal inhibition: 60%). SNAP (20 mg/kg) significantly attenuated catalepsy in males 120 min after haloperidol (44% inhibition), but had no significant effect on females. These results basically agree with literature data showing that NO facilitates central dopaminergic transmission, although the mechanisms are not fully understood. They also reveal the existence of gender-related differences in this nitrergic modulation in mice, with females being less affected than males.

Gender-related differences in the effects of nitric oxide donors on neuroleptic-induced catalepsy in mice

It has been suggested that nigrostriatal dopaminergic transmission is modulated by nitric oxide (NO). Since there is evidence that gonadal hormones can affect extrapyramidal motor behavior in mammals, we investigated the effects of isosorbide dinitrate (ISD), linsidomine (SIN-1) and S-nitroso-N-acetylpenicillamine (SNAP), three pharmacologically different NO donors, on neuroleptic-induced catalepsy in 60- to 80-day-old male and female albino mice. Catalepsy was induced with haloperidol (1 mg/kg, ip) and measured at 30-min intervals by means of a bar test. Drugs (or appropriate vehicle) were injected ip 30 min before haloperidol, with each animal being used only once. ISD (5, 20 and 50 mg/kg) caused a dose-dependent inhibition of catalepsy in male mice (maximal effect 120 min after haloperidol: 64 percent inhibition). In the females only at the highest dose of ISD was an attenuation of catalepsy observed, which was mild and short lasting. SIN-1 (10 and 50 mg/kg) did not significantly affect catalepsy in female mice, while a significant attenuation was observed in males at the dose of 50 mg/kg (maximal inhibition: 60 percent). SNAP (20 mg/kg) significantly attenuated catalepsy in males 120 min after haloperidol (44 percent inhibition), but had no significant effect on females. These results basically agree with literature data showing that NO facilitates central dopaminergic transmission, although the mechanisms are not fully understood. They also reveal the existence of gender-related differences in this nitrergic modulation in mice, with females being less affected than males

Histology of the synovial tissue: value of semiquantitative analysis for the prediction of joint erosions in rheumatoid arthritis.

OBJECTIVE: Routine histologic techniques are still the main procedure in the study of the synovial biopsy. The relationship between the typical histological changes of rheumatoid synovium and clinical manifestations has not been studied in detail. METHODS: With the aim of determining whether a simple semiquantitative method of evaluating the changes in closed synovial biopsies was of clinical value in assessing both the diagnosis and prognosis of rheumatoid arthritis (RA) patients, we evaluated retrospectively 72 synovial biopsy specimens (26 RA patients, 30 patients with other inflammatory diseases and 16 osteoarthritis patients). Scores (0-10) were assigned to each biopsy specimen for each of 6 histologic features: synoviocyte hyperplasia; fibrosis in the subsynovial layer; proliferating blood vessels; perivascular infiltrates of lymphocytes; focal aggregates of lymphocytes; and diffuse infiltrates of lymphocytes. Scores were compared between the 3 groups and also between the RA subgroups with early and late disease; positive and negative rheumatoid factor; with and without joint erosions; and with and without systemic disease. RESULTS: Significant differences in the mean global score (mean of the 6 scores) were found both between RA and osteoarthritis and between other inflammatory diseases and osteoarthritis (p < 0.01). The mean global score for RA was higher than the mean global score obtained for the other inflammatory diseases, but the difference was not significant. We found a significantly higher mean global score in the RA patients with erosions in comparison to the RA patients without erosions, this difference being particularly evident for the lymphocyte perivascular infiltrate (p < 0.05). There were no significant differences between the other RA subgroups. CONCLUSION: In this study we have identified differences, using routine histologic techniques, between the rheumatoid synovial membrane of patients with and without erosions. Based on our present observations we suggest that the intensity of inflammatory histological features and, in particular, a high percentage of vessels with perivascular lymphocyte infiltrate might be of prognostic value in RA.

A complex case of hepatitis in a patient with systemic lupus erythematosus.

Liver involvement in patients with systemic lupus erythematosus (SLE) is considered rare. Previous treatment with potentially hepatotoxic drugs or viral hepatitis have usually been implicated as the main causes of liver disease in SLE patients. On the other hand, even after careful exclusion of these aetiologies, the problem remains whether to classify the patient as having a primary liver disease with associated autoimmune clinical and laboratory features resembling SLE, such as autoimmune hepatitis, or as having liver disease as a manifestation of SLE. We report the case of an elderly woman who presented with acute hepatitis, who had been diagnosed with SLE 14 years ago and who also had Sjögren's syndrome and anti-phospholipid's syndrome for several years. The histology depicted chronic active hepatitis and, after drug-induced hepatitis and viral hepatitis were excluded, the serological and clinical features were shown to be typical of liver damage caused by SLE. The patient was treated with azathioprine 100 mg/d and prednisone 30 mg/d. The clinical symptoms resolved in 10 days and the laboratory values were normal at the end of the first month of therapy. Prednisone was progressively reduced, during a period of 4 months, to 10 mg/d but azathioprine was kept to the same dose. One year after the diagnoses the patient is still in remission. Although uncommon, hepatic involvement is well recognised in SLE. The interest of this case lies in the differential diagnosis and recognition of this condition, which deserves an aggressive treatment.

Evidence of sex related differences in the effects of calcium channel blockers on neuroleptic-induced catalepsy in mice.

1. Calcium channel blockers (CCBs) are reported to affect extrapyramidal motor behavior in mammals. Since sex related differences are a common feature in the pharmacological properties of several centrally active drugs, the authors decided to investigate the effects of verapamil (VER), flunarizine (FLU) and nimodipine (NIM), three pharmacologically different CCBs, on neuroleptic-induced catalepsy in male and female albino mice. 2. Catalepsy was induced with haloperidol (0.75 mg/kg, i.p.) and measured at 30-min intervals by means of a bar test. Drugs (or appropriate vehicle, for the controls) were injected i.p. 20 min before haloperidol, with each animal being used only once. 3. VER (1, 5 and 10 mg/kg) did not significantly affect catalepsy in male mice. In females, however, a significant attenuation of catalepsy was found at the two higher doses. 4. FLU (1, 5 and 10 mg/kg) did not significantly affect catalepsy in male mice, whilst a significant attenuation was observed in females with the doses of 1 and 5 mg/kg (but not with the dose of 10 mg/kg). 5. NIM (3, 10 and 30 mg/kg) potentiated neuroleptic-catalepsy in males at the doses of 10 and 30 mg/kg. In females, however, only the higher dose of NIM caused a potentiation of catalepsy. 6. These results demonstrate the existence of sex related differences in the extrapyramidal effects of CCBs in mice. Further, this sex related effect might depend, among other factors, on the particular channel involved.

Esophageal motility disorders in patients with Sjögren's syndrome.

Esophageal motility was studied in 21 patients with Sjögren's syndrome, and in 25 normal volunteers, in order to record the prevalence and type of esophageal motor abnormalities. Esophageal motor abnormalities were detected in seven of the 21 patients (33.3%). These esophageal abnormalities did not correlate with the presence of dysphagia, the extraglandular involvement, or the presence of autoantibodies.

[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.