Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?

Subclavian artery stenosis (SAS) resulting in coronary subclavian steal syndrome (CSSS) is a common but under recognized pathology following coronary artery bypass surgery (CABG). Patients with SAS may be asymptomatic due to the sub-clinical diversion of blood flow from the myocardium and retrograde blood flow during catheter angiography in the left internal mammary artery (LIMA) may be the first suggestion of CSSS. The management of SAS, causing CSSS, may rarely require acute assessment and intervention. However, full anatomical assessment of the stenosis morphology may be limited on fluoroscopy. Correction of SAS may be essential to achieve effective reperfusion therapy.

The Vanishing Stenosis: ST Elevation Myocardial Infarction and Rhythm Disturbance due to Coronary Artery Spasm-Case Report and Review of the Literature.

A 62-year-old lady was admitted with clinical and electrocardiograph features of acute myocardial infarction. Urgent coronary arteriography was performed, demonstrating a single discrete stenosis of one coronary artery. Following intracoronary injection of GTN, this stenosis completely resolved, as the symptoms did. The causes of acute myocardial infarction with normal coronary arteries are reviewed.

Testosterone in chronic heart failure.

Chronic heart failure is common and can be described as a syndrome characterized by impairment of cardiac function associated with a maladaptive metabolic and neurohormonal axis. The thesis that testosterone replacement therapy may be helpful as a treatment for chronic heart failure may seem at first to be unlikely. Testosterone therapy is widely believed to be deleterious to the cardiovascular system and there is a common misconception that the excess of ischaemic heart disease in young and middle-aged males compared to females is a direct effect of endogenous serum testosterone levels. In this chapter we will present the published evidence of the effects of endogenous and therapeutic testosterone on the heart and the human cardiovascular system with an emphasis on the pathologic syndrome of chronic heart failure. There is developing evidence that of all morbid populations, patients with chronic heart failure in particular are likely to benefit from testosterone treatment since the natural history is that of progressive disordered metabolism with catabolic excess and androgen imbalance.

Androgens, insulin resistance and vascular disease in men.

Type 2 diabetes mellitus is increasing globally and is an established risk factor for the development of atherosclerotic vascular disease. Insulin resistance is the hallmark feature of type 2 diabetes and is also an important component of the metabolic syndrome. There is evidence to suggest that testosterone is an important regulator of insulin sensitivity in men. Observational studies have shown that testosterone levels are low in men with diabetes, visceral obesity (which is strongly associated with insulin resistance), coronary artery disease and metabolic syndrome. Short-term interventional studies have also demonstrated that testosterone replacement therapy produces an improvement in insulin sensitivity in men. Thus hypotestosteronaemia may have a role in the pathogenesis of insulin-resistant states and androgen replacement therapy could be a potential treatment that could be offered for improvements in glycaemic control and reduction in cardiovascular risk, particularly in diabetic men.

Testosterone does not adversely affect fibrinogen or tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) levels in 46 men with chronic stable angina.

OBJECTIVE: In women, sex hormones cause increased morbidity and mortality in patients with coronary heart disease (CHD) and adversely affect the coagulation profile. We have studied the effect of physiological testosterone replacement therapy in men on coagulation factor expression, to determine if there is an increased risk of thrombosis. METHODS: Double-blind, randomized, placebo-controlled trial of testosterone in 46 men with chronic stable angina. Measurements of free, total and bioavailable testosterone, luteinising hormone (LH) and follicle-stimulating hormone (FSH), estradiol, plasminogen activator inhibitor-1 (PAI-1), fibrinogen, tissue plasminogen activator (tPA) and full blood count were made at 0, 6 and 14 weeks. RESULTS: Bioavailable testosterone levels were: 2.58 +/- 0.58 nmol/l at baseline, compared with 3.35 +/- 0.31 nmol/l at week 14 (P < 0.001) after treatment compared with 2.6 +/- 0.18 nmol/l and 2.44 +/- 0.18 nmol/l in the placebo group (P was not significant). There was no change in fibrinogen (3.03 +/- 0.18 g/l at baseline and 3.02 +/- 0.18 g/l at week 14, P = 0.24), tPA activity (26.77 +/- 4.9 Iu/ml and 25.67 +/- 4.4 Iu/ml, P = 0.88) or PAI-1 activity (0.49 +/- 0.85 Iu/ml and 0.36 +/- 0.06 Iu/ml, P = 0.16) with active treatment and no differences between the groups (at week 14, P value 0.98, 0.59 and 0.8 for fibrinogen, PAI-1 and tPA respectively). Haemoglobin concentration did not change over time, in the testosterone group (1.44 +/- 0.02 g/l and 1.45 +/- 0.02 g/l, P = 0.22). CONCLUSION: Physiological testosterone replacement does not adversely affect blood coagulation status.

Life-saving or life-prolonging? Interpreting trial data and survival curves for patients with congestive heart failure.

Chronic heart failure is responsible for considerable suffering and mortality throughout the world. Clinical trials have consistently demonstrated the benefits of pharmacological therapies such as angiotensin-converting enzyme inhibitors and beta-adrenoceptor blockers. These drugs are often quoted as reducing mortality from heart failure, yet all patients with heart failure deteriorate and most will die because of their disease. Therapies in heart failure are not truly life saving; they modify the natural history of the disease and delay the time to deterioration. The time benefit in survival is not usually reported in clinical trials, which are conducted over fixed time points and report risk reductions during this period only. In this paper, we discuss the use of prolongation of life statistics as an outcome measure in clinical trials and review simple techniques for calculating the lifetime benefit of pharmacological intervention in heart failure using data from a number of major studies

Testosterone replacement in hypogonadal men with angina improves ischaemic threshold and quality of life.

BACKGROUND: Low serum testosterone is associated with several cardiovascular risk factors including dyslipidaemia, adverse clotting profiles, obesity, and insulin resistance. Testosterone has been reported to improve symptoms of angina and delay time to ischaemic threshold in unselected men with coronary disease. OBJECTIVE: This randomised single blind placebo controlled crossover study compared testosterone replacement therapy (Sustanon 100) with placebo in 10 men with ischaemic heart disease and hypogonadism. RESULTS: Baseline total testosterone and bioavailable testosterone were respectively 4.2 (0.5) nmol/l and 1.7 (0.4) nmol/l. After a month of testosterone, delta value analysis between testosterone and placebo phase showed that mean (SD) trough testosterone concentrations increased significantly by 4.8 (6.6) nmol/l (total testosterone) (p = 0.05) and 3.8 (4.5) nmol/l (bioavailable testosterone) (p = 0.025), time to 1 mm ST segment depression assessed by Bruce protocol exercise treadmill testing increased by 74 (54) seconds (p = 0.002), and mood scores assessed with validated questionnaires all improved. Compared with placebo, testosterone therapy was also associated with a significant reduction of total cholesterol and serum tumour necrosis factor alpha with delta values of -0.41 (0.54) mmol/l (p = 0.04) and -1.8 (2.4) pg/ml (p = 0.05) respectively. CONCLUSION: Testosterone replacement therapy in hypogonadal men delays time to ischaemia, improves mood, and is associated with potentially beneficial reductions of total cholesterol and serum tumour necrosis factor alpha.

Testosterone as a protective factor against atherosclerosis--immunomodulation and influence upon plaque development and stability.

Inflammation plays a central pathogenic role in the initiation and progression of coronary atheroma and its clinical consequences. Cytokines are the mediators of cellular inflammation and promote local inflammation in the arterial wall, which may lead to vascular smooth muscle apoptosis, degradation of the fibrin cap and plaque rupture. Platelet adhesion and thrombus formation then occur, resulting clinically in unstable angina or myocardial infarction. Recent studies have suggested that cytokines are pathogenic, contributing directly to the disease process. 'Anti-cytokine' therapy may, therefore, be of benefit in preventing or slowing the progression of cardiovascular disease. Both oestrogens and testosterone have been shown to have immune-modulating effects; testosterone in particular appears to suppress activation of pro-inflammatory cytokines. Men with low testosterone levels are at increased risk of coronary artery disease. An anti-inflammatory effect of normal physiological levels of sex hormones may, therefore, be important in atheroprotection. In this Article, we discuss some of the mechanisms involved in atherosclerotic coronary artery disease and the putative link between testosterone deficiency and atheroma formation. We present the hypothesis that the immune-modulating properties of testosterone may be important in inhibiting atheroma formation and progression to acute coronary syndrome.

Investigation of anthropometric and work-rate profiles of Rugby Sevens players.

BACKGROUND: To describe anthropometric and match performance profiles of international Rugby Sevens players and explore correlations between anthropometric characteristics and work-rates in matches. METHODS: Profiles were compared by means of multivariate analysis and correlation techniques. SETTINGS: measurements were made on players participating in the 1996 International Rugby Sevens tournament in Uruguay. SUBJECTS: Thirty male players. MEASURES: work-rate analysis during matches (n = 30) and a comprehensive anthropometry profile of 27 of the 30 players. RESULTS: Forwards had more mass (whole-body, adipose tissue, muscle) than backs, jogged more frequently and paused more often. High intensity activity was negatively correlated with muscle mass and with mesomorphy. CONCLUSIONS: Anthropometric features are related to components of match play in Rugby Sevens but do not necessarily determine whether a game is won or lost.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods.

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

[Fractures of the proximal femur].

907 patients were operated on for fracture of the proximal femur in 1986-1987 and were then followed for an average of 7 months. There was a relatively high rate of complications in those over the age of 71, in whom mortality reached 15.5%, while the overall mortality was 6.8%. There was also a high rate of complications in those operated 3 or more days after the fracture had occurred. In those up to the age of 60, the ratio of males to females was almost 1 to 1, but in those over 80 the ratio was 1 to 4. The mortality of males was higher (9.2%) than that of females (5.5%). In trochanteric fractures treated by various methods of rigid fixation there were no problems of union or delayed union. Early mobilization and early discharge from hospital reduced mortality and complications.

Blood levels of vitamin D metabolites in gonarthrosis.

The blood levels of the active metabolites of vitamin D3 25-hydroxycholecalciferol [25(OH)D3]. 1,25-dihydroxycholecalciferol [1,25(OH)2D3], and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in 27 patients suffering from arthrosis of the knee, including 4 patients with non-insulin-dependent diabetes mellitus. The blood level of 24,25-dihydroxycholecalciferol was found to be significantly lower in patients with gonarthrosis than in patients with coxarthrosis. With the exclusion of the diabetic patients, the mean value for this metabolite was lower than in the coxarthrosis group, but the difference was not significant statistically.

Preoperative and postoperative gait evaluation in cerebral palsy.

The purpose of the study was to evaluate objectively and quantitatively the possible effects of surgical correction for equinus deformity on the gait of children with cerebral palsy (CP). Evaluation criteria selected were based on time and distance parameters of stride during gait. Ten children with confirmed diagnoses of CP took part in the study. They were tested before surgery and after surgery at four-month intervals for a period of up to one year. Results were compared to published data obtained on able-bodied, growing children to determine whether progress after the operation was faster than that expected in normal growth. Gait improvement was demonstrated by a decrease in support time and an increase in walking speed and stride length. Overall improvement was sometimes preceded by an initial, temporary deterioration. Results indicate that the time and distance parameters of stride can provide reliable objective evaluation of gait improvement after tendo Achilles lengthening in children with CP.

Blood levels of active metabolites of vitamin D3 in fracture repair in humans. A preliminary report.

Blood levels of the active metabolites of vitamin D3, 25-hydroxycholecalciferol [25(OH)D3], 1,25-dihydroxycholecalciferol [1,25(OH)2D3] and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in seven patients. Two subjects suffered from delayed union of tibial fractures; one showed a delayed union after a proximal tibial osteotomy; one patient suffered from bilateral femoral neck fractures, of which one failed to unite and the other united late; two patients had multiple fractures that united normally; and one patient exhibited staged bilateral femoral neck fractures whose occurrence was separated by a short interval and which united without undue delay. The blood levels of 25(OH)D3 were within the normal range. A relative decrease in 24,25(OH)2D3 values was noted in all patients, whereas in three subjects the decrease was absolute, to non-detectable levels. A decrease in 1,25(OH)2D3 levels was noted in only two patients. We postulate that these changes reflect the consumption of these metabolites during healing at the fracture site.

Active metabolites of vitamin D in patients with coxarthrosis and with aseptic loosening of total hip endoprostheses.

The blood levels of the active metabolites of vitamin D--25-hydroxycholecalciferol (25(OH)D), 1,25 dihydroxycholecalciferol (1,25(OH)2D), and 24,25 dihydroxycholecalciferol (24,25(OH)2D)--were determined in 15 patients suffering from arthrosis of the hip and in 13 patients with aseptic loosening of total hip endoprostheses. Normal values were found in all but one patient with aseptic loosening, in whom 24,25(OH)2D was not detectable. The difference between the two groups of patients was not statistically significant.

Progressive valgus deformity after juxta-epiphyseal fractures of the upper tibia in children.

Four cases of progressive valgus deformity following a juxta-epiphyseal fracture of the proximal end of the tibia are presented. We suggest that the deformity is due to asymmetrical growth of the physis. Since this type of fracture tends to create a deformity, an anatomical or even overcorrected reduction is required. Long follow-up is necessary.