Predictors of remission, erosive disease and radiographic progression in a Colombian cohort of early onset rheumatoid arthritis: a 3-year follow-up study.

The objective of the study is to find predictors of remission, radiographic progression (RP), and erosive disease in a cohort of patients with early onset rheumatoid arthritis (EORA) that followed a therapeutic protocol aiming at remission, in a real world tight-control setting. EORA patients were enrolled in a 3-year follow-up study. Clinical, biological, immunogenetic, and radiographical data were analyzed. Radiographs were scored according to Sharp-van der Heijde (SvdH) method. RP was defined by an increase of 3 units in 36 months. Remission was defined as DAS28 <2.6. A stepwise multiple logistic regression model was used to identify independent predictors of the three target outcomes. One hundred twenty-nine patients were included. Baseline disease activity was high. Significant overall improvement was observed, but only 33.3 % achieved remission. At 36 month, 50.4 % (65) of patients showed erosions. RP was observed in 62.7 % (81) of cases. Statistical analysis showed that baseline SvdH score was the only predictive factor associated with the three outcomes evaluated. Lower HAQ-DI and absence of autoantibodies were predictive of remission. Higher levels of ESR and presence of erosions at entry were predictive of RP. Independent baseline predictors of incident erosive disease were anti-CCP and RF positivity, symptom duration at baseline >3 months, and presence of HLA-DRB1 shared epitope. Radiographic damage at baseline was the main predictor of outcomes. Autoantibodies, HAQ and ESR at baseline, symptom duration before diagnosis, and HLA-DRB1 status had influence on clinical course and development of structural joint damage in Colombian RA patients.

Patients with relapsing polychondritis and previous cartilage trauma present more autoimmunity phenomena.

Relapsing polychondritis (RP) is an autoimmune disease characterized by inflammation and destruction of all type of body cartilage, and the cartilage trauma may be a trigger of the disease in a susceptible person. We describe the clinical and laboratory findings in a group of 18 patients with RP with (7 cases) or without (11 cases) anteceding cartilage trauma. The mean age was 41 years in the group with cartilage trauma and 55 years in the group without cartilage trauma. For both groups, female gender was predominant. All patients presented with auricular chondritis. Systemic manifestations and autoimmunity were more common in patients with anteceding trauma.

El papel de la medicina forense en el contexto del trabajo humanitario / Rol of forensic medicine in the context of humanitarian work

Actualmente la medicina forense tiene campos de acción más amplios e incluye el campo humanitario. Las Convenciones de Ginebra y los protocolos adicionales incluyen reglas claras referentes al manejo de los cadáveres y la responsabilidad de las diferentes autoridades o grupos en conflicto para identificarlos y disponer de ellos, de manera que sea posible recuperarlos más tarde y entregarlos a sus familias. El Comité Internacional de la Cruz Roja ha sido la organización pionera en estas labores, e igualmente Naciones Unidas e INTERPOL, entre otras organizaciones públicas, privadas y ONGs; emplean actualmente protocolos y guías de trabajo para contextos de atención humanitaria y prevención de violaciones al Derecho Internacional Humanitario. El empleo de la medicina forense en diferentes partes del mundo ha sido y seguirá siendo un componente importante de las misiones humanitarias (AU)

Today the forensic medicine has broader action fields including the humanitarian activities. The Geneva Conventions and additional protocols have clear rules about the management of dead bodies and the responsibility of many authorities or armed groups in conflict in order to identify those bodies and to deal with them in such manner that facilitate late recovery and to bring them back to their relatives. The International Committee of the Red Cross has been the pioneer organization in those tasks, also United Nations and INTERPOL, among other public and private organizations and NGOs, are applying protocols and guidelines to jobs in the humanitarian context and prevention of violations of the International Humanitarian Law. The use of forensic medicine around the world has been and will continue being an important component of humanitarian missions (AU)

Apo(a) phenotyping and long-term prognosis for coronary artery disease.

OBJECTIVES: Identify whether the plasma concentration of Lp(a), apo(a) size or a greater affinity for fibrin predict the likelihood of cardiac death, non-fatal myocardial infarction, unstable angina, the need for additional revascularization, and stroke (MACCE). DESIGN AND METHODS: We analyzed the clinical prognosis of 68 patients with coronary artery disease included in a case-controlled study which evaluated Lp(a) concentration, apo(a) size, and Lp(a) fibrin-binding. Cohort was conducted over a median of 8 years. We used Kaplan-Meier survival tables to evaluate cardiovascular and cerebrovascular events in the follow-up period. RESULTS: Apo(a) isoforms of small size are predictors of MACCE. We find an association between Lp(a) concentration and apo(a) fibrin-binding with major adverse cardiovascular and cerebrovascular events, although without statistically significant results. CONCLUSIONS: Small-sized apo(a) isoforms are an independent risk factor for MACCE in patients with coronary artery disease in follow-up. Lp(a) plasma concentration and apo(a) fibrin-binding were associated, although not significant.

[Angiogenesis]. / Angiogénesis.

Angiogenesis refers to a process of new vessel formation originated from pre-existent vessels. This mechanisms requires a series of complex events that include pro-angiogenic and anti-angiogenic molecules. Among the angiogenic factors studied are the fibroblast growth factor (FGF) and the vascular endothelial growth factor (VEGF). Recently, great efforts have been made to apply these factors to the treatment of advanced and chronic ischemic heart disease and for peripheral arterial disease. The present paper reviews angiogenic mechanisms as well as experimental and clinical studies reported in the literature.

Comparative trial of stent-like balloon angioplasty versus coronary stenting for acute myocardial infarction.

Primary PTCA has been shown to be superior to any thrombolytic regimen and offers higher reperfusion rates and better coronary flow grades. Its limitations include recurrent ischemia (10%-15%), infarct-related artery reocclusion (5%-10%), angiographic restenosis (35%-50%), and need to perform repeat PTCA or CABG at 6-month follow-up (20%). Thus, the current role of coronary stenting for acute myocardial infarction (AMI) is very promising. From December 1995 through January 1997, 335 patients underwent primary angioplasty during the first 12 hr from symptom onset at our institution. We performed a retrospective study comparing the in-hospital and 6-month follow-up outcome of 61 patients who underwent coronary stenting (stent group) against 61 patients with optimal (residual lesion stenosis < 30%) balloon-only primary angioplasty (stent-like group). Patients were routinely treated with aspirin, and ticlopidine was given only to the stent group. In-hospital major adverse cardiac events (MACE) rate was 11.5% without statistical differences between the groups. Cardiac death rate was similar in both groups (4.9 vs. 6.6%; P = 1.0) and only two (3.3%) patients from the stent group and none from the PTCA group had nonfatal myocardial reinfarction. At 6-month follow-up, the rate of recurrent angina was higher in the stent-like group (30.9 vs. 7.1%; P < 0.001). Multivariate analysis showed that only stenting of the infarct-related artery was a borderline independent predictor for MACE (OR = 0; 95% CI = 0-1; P = 0.057). Primary stenting for AMI reduces the rate of recurrent angina or symptoms and MACE at 6-month follow-up.

[The benefit of a coronary stent in the reduction of major cardiac complications in acute coronary syndromes]. / Beneficio del stent coronario en la reducción de complicaciones cardiacas mayores en síndromes coronarios agudos.

To assess the incidence of in-hospital major adverse cardiac events (MACE), we analyzed 694 procedures in 613 consecutive patients during one year period. Patient population included 550 (79.2%) patients with unstable angina, 43 (6.2%) with stable angina and 101 (14.5%) with acute myocardial infarction. Elective percutaneous transluminal coronary angioplasty (PTCA) was performed in 593 (85.4%) patients, rescue PTCA in 7 (1%), and primary PTCA in 94 (13.5%). Angiographic lesion morphology was as follows: type A 30%; type B 58%; type C 12%. We compared patient population who received stent with PTCA-balloon only. Technical success was 95% and clinical success was achieved in 80% of the cases. Overall mortality was 1% in the stent group and 3% in the conventional PTCA. The incidence of MACE was 4% and 15.1% in the stent and angioplasty balloon groups respectively. We found a dramatic impact on reduction of the incidence of acute complications in the groups with stenting for unstable angina (p = 0.0001) and acute myocardial infarction (p = 0.0001). The major clinical advantage of stenting over balloon angioplasty was a lower need for repeated procedures.

[Translumbar coronary angiography and aortography in a patient with Takayasu's arteritis]. / Arteriografía coronaria y aortografía por vía translumbar en una paciente con arteritis de takayasu.

Since its introduction by Dos Santos in 1929, arterial angiography by translumbar percutaneous approach has suffered some transformations. Nowadays it has been replaced by other percutaneous approaches and it is indicated only when these routes of access have failed due to aortoiliac or subclavian arteries obstruction. This report presents a patient with Takayasu's Arteritis with severe peripheral arterial obstruction and unstable angina, who underwent coronary arteriography and aortography by translumbar approach. A review of this technique is made.

[The no-reflow phenomenon: its incidence and clinical characteristics in a series of cases]. / Fenómeno de no-reflujo: incidencia y características clínicas en una serie de casos.

The no-reflow phenomenon refers to the inability to reperfuse myocardial tissue despite removal of an occlusion of a coronary artery. No reflow is a complication that may occur after revascularization of patients. This study examined the incidence and, clinical characteristics of no-reflow in a patient population treated with conventional percutaneous transluminal coronary angioplasty at the Instituto Nacional de Cardiología "Ignacio Chávez". We reviewed 204 elective angioplasties and 62 direct angioplasties; 14 patients were included (4 from the first group and 10 from the second group). No-reflow were more frequently in men, the mean age was 56 years and diabetes and smoking were the risk factors more frequently reported. No-reflow was found in left anterior descending coronary artery in 7 patients, the time of reperfusion, in direct angioplasty, was 10.6 hours (mean) and the strategy most frequently used to reestablish normal anterograde flow was intracoronary verapamil. The overall incidence of no-reflow for the two modalities was 5.2% (16.12% for direct angioplasty and 1.9% for elective angioplasty). The current study shows that the no-reflow phenomenon is not uncommon after angioplasty; no-reflow appears higher than the previous reports for both modalities of treatment.

[Coronary stent in acute myocardial infarction]. / Stent coronario en el infarto agudo del miocardio.

UNLABELLED: From December 1995 to March 1997 fifty patients with acute myocardial infarction, had 57 stents implanted. Mean time since the beginning of symptoms to the procedure was 3.7 +/- 2.9 hours. Twenty-four stents were implanted "de novo", 17 for "sub-optimal" results, 5 for threatened closure and eleven for complex dissection. The arteries treated with stent were left anterior descending in 42%, right coronary in 42%, circumflex in 10%, vein grafts in 4%, intermedial branch in 1% and marginal obtuse branch in 1%. Stent used in most of the cases was AVE in 67% followed by Palmaz-Schatz, Wiktor, Crown, Gianturco-Roubin and Wallstent. Before procedure, coronary flow was TIMI 0 in 66% TIMI 1 in 10% and TIMI 2 in 24%. After procedure, TIMI 3 coronary flow was achieved in 92% of the arteries and other four had "no-reflow" phenomenon. Mean stenosis before procedure was 96% +/- 3.1 and after stenting was 1.76% +/- 2.6 with a stent/artery diameter rate of 1.01. Technical success was 100% and clinical success was achieved in 96% of the cases. Two cases were not successfully due to acute thrombotic closure in one patient and in another one because of cardiogenic shock after two days of a technical successful implantation of stent in LAD artery. There were not recurrent ischemic events (CABG, re-infarction or new coronary angioplasty procedure). Other two patients died for non-cardiac events (acute pancreatitis in one and by septic shock in other). At the time of discharge 96% of patients were treated with aspirin and ticlopidine. Major hematoma was evident in only one case. At a mean follow-up time of 5.6 months +/- 4.2 in 45 patients showed that 73% were in functional class I and none of them had re-infarction, death or needed a new revascularization. CONCLUSION: Stent implantation in acute myocardial infarction is feasible and safe procedure with a low rate of ischemic recurrent events.

[Late thrombolysis and electrical stability in acute myocardial infarction. Role of the collateral flow]. / Trombolisis tardía y estabilidad eléctrica en el infarto agudo del miocardio: importancia del flujo colateral.

We evaluated 249 patients (pts) with first acute myocardial infarction: 1. Pts without thrombolysis, n = 119, 2. Pts treated with thrombolysis within 6 hours following MI, n = 80 and 3. Pts treated with thrombolysis between 6-12 hours after MI. Arrhythmic events were evaluated during follow up. All underwent heart rate variability studies and coronary angiogram where anterograde flow (TIMI) and collateral flow (Rentrop scale 0-2 = poor collateral flow and 3 = good collateral flow) were determined. Pts in group 2 and 3 showed a better anterograde and collateral flow than group 1 (p < 0.001). A lower spectral power in the high frequency band and a higher ratio low/high frequency band were observed in group 1 (p < 0.05). Conjunctive consolidation analysis showed more malignant arrhythmias in TIMI 0-2 with poor collateral flow than TIMI 0-2 with good collateral flow (17/138-12.3% vs 0/14-0%). Kaplan Meier analysis was able to demonstrate more cardiac sudden death events in TIMI 0-2 with poor collateral flow than TIMI 0-2 with good collateral flow or TIMI 3 (x2 = 7.22, p = 0.028), independently of thrombolytic treatment.

[Primary angioplasty: comparison of working hours and night]. / Angioplastía primaria: comparación entre los horarios matutino y nocturno.

A prospective, observational, comparative study of 100 patients with acute myocardial infarction and primary angioplasty was performed to establish if there was statistically difference between the lag of time when symptoms begin and the time of the emergency admission to the time of arrival at the catheterization suite during working hours vs the "on call" hours. Patients were allocated in two groups accordingly to morning hours or on call hours. Time of onset of symptoms to the catheterization suite arrival between the two groups was no significantly different. Time from emergency room arrival to catheterization suite arrival was significant different < 0.05, however success rate between groups 86% vs 80% and complications rate were statistically non significant between both groups. We conclude that primary angioplasty is a highly effective method of reperfusion. Even though the time from the emergency room arrival to the catheterization suite arrival was significantly less during day than the on call hours, there is no difference between the success rate and complications incidence in both groups.

[Coronary stents. Results during the hospitalization phase]. / Stent coronario. Resultados en fase hospitalaria.

UNLABELLED: Between October 1991 and August 1996 two-hundred coronary stents were implanted (s) in 166 patients (pts) (1.27 s/pt). One hundred thirty-five lesions "de novo" were approached with stent, 44 because of a sub-optimal result post-angioplasty, 15 for restenosis and 17 for dissection. In thirty-six patients the indication of stenting was stable angina, in 68 unstable angina, in 37 for angina after myocardial infarction, in 11 for asymptomatic ischemia after myocardial infarction and in 14 during an acute myocardial infarction. Mean stenosis before stent implantation in all cases was 85 +/- 15%. Type of lesion in seventy cases was A, in 112 was B and 29 was C. Stents used were AVE in 146 lesions, Palmaz-Schatz in 33, Wiktor in 23, Gianturco-Roubin in 8 and Wallstent in one case. Medical treatment in 140 pts. (84.3%) after stent implantation was only with aspirin and ticlopidine. Technical success in all patients was 98.6% (208/211 pts) and primary success was 94.6% (157-166 pts). Unsuccessful procedures were because of sub-acute occlusion in three patients (1.8%), death in 3 pts. (1.8%) and urgent CABG was necessary in one pt. (0.5%). Major hematoma was a complication in 5 pts (3%). Mean residual stenosis after stent implantation in all cases was 2.2%. CONCLUSION: Stent implantation in our laboratory is a very safe procedure with a high rate of primary success with lowest complications in a great population of unstable angina.

[Thrombolysis in acute myocardial infarct of embolic origin]. / Trombolisis en infarto agudo del miocardio de origen embólico.

Myocardial infarctions which are derived from embolic source have an incidence of 5-13%. They are at risk of systemic embolism. The pathogenesis of myocardial infarction is similar to that of those myocardial infarction whose etiology is atherosclerosis. This make it susceptible to thrombolysis. We report 3 patients with either inactive rheumatic heart disease, coarctation of the aorta or mechanical valvular prosthesis as the probable causes of an embolic infarction. It was located in the posterior-inferior region with a dorsal extension. These patients were treated with intravenous streptokinase. The three of them fulfilled criteria for myocardial reperfusion. Two of them suffered post-infarction angina. In the first case reocclusion of the righ coronary artery was observed; thus a saphenous vein graft was undertaken. In the second, the persistence of thrombus required three month treatment with anticoagulants. The third patient showed not coronary lesions. In conclusion, thrombolytic therapy with streptokinase in acute infarction of embolic origin prevents the progression of ischemic damage and betters the clinical outcome of the patient. Furthermore such disease should be suspected in patients that have risk factors for systemic embolism and normal coronary arteries and with obstruction of a single vessel.