Liver morphology with emphasis on bile ducts changes and survival analysis in mice submitted to multiple Schistosoma mansoni infections and chemotherapy.

In an attempt to be as close as possible to the infected and treated patients of the endemic areas of schistosomiasis (S. mansoni) and in order to achieve a long period of follow-up, mice were repeatedly infected with a low number of cercariae. Survival data and histological variables such as schistosomal granuloma, portal changes, hepatocellular necrosis, hepatocellular regeneration, schistosomotic pigment, periductal fibrosis and chiefly bile ducts changes were analysed in the infected treated and non treated mice. Oxamniquine chemotherapy in repeatedly infected mice prolonged survival significantly when compared to non-treated animals (chi-square 9.24, p = 0.0024), thus confirming previous results with a similar experimental model but with a shorter term follow-up. Furthermore, mortality decreased rapidly after treatment suggesting an abrupt reduction in the severity of hepatic lesions. A morphological and immunohistochemical study of the liver was carried out. Portal fibrosis, with a pattern resembling human Symmers fibrosis was present at a late phase in the infected animals. Bile duct lesions were quite close to those described in human Mansonian schistosomiasis. Schistosomal antigen was observed in one isolated altered bile duct cell. The pathogenesis of the bile duct changes and its relation to the parasite infection and/or their antigens are discussed.

[Incidence of dyslipidemia and its relation to coronary artery disease in Brazilian populations]. / Incidência de dislipidemia e sua relação com doença arterial coronária em populações brasileiras.

PURPOSE: To describe the incidence of dyslipidemia and its relation to coronary artery disease (CAD) in two brazilian populations. PATIENTS AND METHODS: 1.261 subjects were analyzed; 674, whose mean age was 53 years, came from a cardiology private office (population A) and 587, whose mean age was 37 years, were employees of an engineering company (population B). Cholesterol was determined by the enzymatic method Chod-pap and LDL calculated by the Friedwald's formula. RESULTS: CAD was present in 35.1% of population A and in 1.4% of population B. In population A total cholesterol and LDL were above the expected, in all age groups. About 70% of these patients had cholesterol greater than 200 mg% and LDL greater than 130 mg%, which are considered desirable levels; 28% of women and 44% of men had HDL less than 35 mg%. Conversely, in population B total cholesterol and LDL were slightly above normal only in patients greater than 45 years old. In addition, about 65% of population had cholesterol less than 200 mg% and LDL less than 130 mg%; even so, 28% of women and 48% of men had HDL less than 35 mg%. In population A, there were no significant differences between the percentages of patients with and without CAD, over a wide range of cholesterol values. Similarly, levels of LDL, HDL and triglycerides as well as the incidence of hypertension, smoking and diabetes did not differ between patients with and without CAD. CONCLUSION: There is a high incidence of dyslipidemia in these brazilian populations, especially among patients from private office. Further, the isolated measurement of lipid fractions does not discriminate between patients with and without DAC, suggesting that other factors are involved in the genesis of the disease.

[Prevalence of primary dyslipidemia in subjects with and without family history of coronary disease, based on the reference values of the "National Cholesterol Education Program" (NCEP)]. / Prevalência de dislipidemias primárias em indivíduos com e sem história familiar de coronariopatia, tendo como referência os valores do "National Cholesterol Education Program" (NCEP).

PURPOSE--To compare the prevalence of primary dyslipidemia in 2 groups, based on NCEP guidelines: a) first degree relatives of revascularized patients and b) hospital employees without family history of coronary heart disease (CHD). METHODS--1162 subjects aged over 20 years, were divided in two groups: G Fam consisted of 312 women and 221 men, mean age 30.8 years, siblings, brothers or sisters of revascularized patients (under 55 years old); G Serv consisted of 425 women and 204 men, mean age 30.7 years, all of them being healthy employees of Hospital das Clínicas (Clinics Hospital) with no family history of CHD. There were performed clinical, electrocardiographic and laboratory tests (total blood cholesterol--CT, triglycerides--TG and HDL cholesterol--HDL-C): and VLDL-C and LDL-C values were calculated according to Friedwald, besides CT/HDL-C and LDL-C/HDL-C ratios. Based on NCEP guidelines, the frequencies on values ranges for each parameter were determined. RESULTS--G Fam group showed a higher incidence of women and men with CT and LDL-C levels above 240 mg/dl and 160 mg/dl, respectively; CT/HDL-C and LDL-C/HDL-C values over 5.0 and 3.5, respectively, were seen more often in G Fam group. There were no significant differences on HDL-C and TG. About 35% of men and women in G Serv group showed CT levels higher than 200 mg/dl. CONCLUSION--First-degree relatives, aged over 20 years, from revascularized patients under 55 years old, showed more often lipid levels above those established by NCEP. In accordance to them, 62% of men and 28% of women of this group should undergo to LDL-C analysis, as well as 35% of men and 28% of women in teh G Serv group. It is called the attention for the importance of cholesterolemia evaluation in high risk groups for CHD.

[The relationship between left ventricular function and the precipitation of symptoms in severe chronic aortic insufficiency]. / Relação entre função ventricular esquerda e desencadeamento de sintomas na insuficiência aórtica crônica severa.

PURPOSE: To study the relationship between symptoms and left ventricular function in 68 patients with severe chronic aortic regurgitation using echocardiogram and radionuclide left ventriculography at rest. METHODS: Three stages of natural history are assumed: the 1st, at the beginning of the study, when all patients were asymptomatic (clinical stage 0); the 2nd, at the end of 36 month persistence of asymptomatic (clinical stage 1), consisting of 45 patients (group AA); the 3rd, on occasion of manifestation of the symptoms during this period of time (clinical stage 2), consisting of 21 patients (group AS-PRE), with two fatalities not related to valvopathy. RESULTS: The comparison between the groups resulted in similarities in the mean ages, mean time of knowledge of the disease, predominance of males and rheumatic etiology. The profile analysis showed that the significant initial differences between the average of all echocardiographic variables (diastolic diameter, systolic diameter, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and of the ejection fraction of the left ventricle obtained by the radionuclide ventriculography at rest, remained during the study. CONCLUSION: Development of symptoms grouped patients with more advanced excentric hypertrophy, did not coincide with any immediate change in the laboratory markers studied at rest and it was used as a referential for surgical therapy.

[Relationship between ventricular arrhythmia and cardiac function in Chagas disease]. / Relação entre arritmia ventricular e função cardíaca na doença de Chagas.

PURPOSE: It is well established the association between heart failure and arrhythmias in different cardiopathies. There are no studies in Chagas' myocardiopathy that analyze the relation between arrhythmias and left ventricular function. METHODS: We studied 629 patients with Chagas' disease, divided in 3 groups, according to ejection fraction obtained through echocardiographic study (normal, between 0.64 and 0.45, and below 0.44). RESULTS: At conventional ECG, the presence of ventricular arrhythmias was respectively in the 3 groups: 15%, 36% and 64%, showing higher incidence when left ventricular function was getting worse. CONCLUSION: Ventricular arrhythmias in Chagas' disease are frequent in patients with normal ejection fraction, and become more intense as ventricular dysfunction progresses.

[Maximal functional capacity and diastolic function in patients with cardiomyopathy due to Chagas' disease without congestive heart failure]. / Capacidade funcional máxima e função diastólica em portadores de cardiomiopatia chagásica sem insuficiência cardíaca congestiva.

PURPOSE: To identify early cardiac dysfunctions in asymptomatic patients with Chagas' cardiomyopathy. METHODS: We studied 38 male individuals: control group consisting of 20 sedentary normal individuals and Chagas' group, of 18 asymptomatic patients with Chagas' disease, with suggestive electrocardiographic alterations and normal fractional shortening (FS) on echocardiogram. Both groups were submitted to evaluation of the maximal functional capacity, with measurements of maximal O2 consumption (VO2max), O2-pulse rate (PO2max), maximal ventilation (VEmax), maximal heart rate (HRmax), and anaerobic threshold of the VO2max (VO2-AT). Left ventricular diastolic function was evaluated by conventional echocardiography (E wave, A wave and E/A ratio). RESULTS: No significant differences occurred between the two groups with regard to FS (p = 0.212) and age means (p = 0.060). The 2 groups were significantly different (p < 0.001) regarding the parameters VO2max, PO2max, VEmax, HRmax and VO2-AT, E wave and E/A ratio. There was no difference (p = 0.520) in A wave. CONCLUSION: Impaired ventricular function may account for the above mentioned differences, a consequence of both systolic and diastolic dysfunctions.

[Myocardial infarction: comparison of anatomo-pathological findings from hearts with and without severe coronary atherosclerosis in 194 necropsy cases]. / Infarto do miocárdio: comparação dos achados anátomo-patológicos em corações com e sem aterosclerose coronária grave em 194 casos de necrópsia.

PURPOSE: To compare morphological features of myocardial infarction (MI) from patients with any epicardial coronary artery narrowed at some point more than 70% (severe coronary atherosclerosis--SCA) with those from patients with either no coronary atherosclerosis or only mild (less than 70%) atherosclerosis. METHODS: Necropsy findings from 194 patients who died due to MI, 174 patients with and 20 without SCA. Ages ranged from 21 to 82 (mean 60) years. RESULTS: Mean age was 60 years in the cases with SCA and 56 in the case without it; nevertheless, age distribution was different (p = 0.023), due to the existence of more patients under age 40 in the group without SCA. There was no significant difference concerning sex (31.0% of female patients in the group with SCA and 35.0% in the other group, p = 0.718), mean heart weight (500 g and 506 g), distribution of cases according to time of evolution of MI in recent only, old only or both (cases with SCA--36.2%, 28.2% and 35.6%; cases without SCA--45.0% and 20%; p = 0.666), left ventricular wall committed by the MI (p = 0.715), incidence of hemorrhagic infarction (with SCA--8.6%; without SCA--15.0%; p = 0.406), left ventricular rupture (with SCa--5.17%, without SCA--10.0%; p = 0.719) and left ventricular aneurysms (with SCA--12.1%, without SCA--15.0%; p = 0.316). An association was found between coronary atherosclerosis and recent (p = 0.046) and recanalized (p less than 0.001) thrombosis, but absent when only recent thrombosis and non-operated cases with recent MI were considered (p = 0.091). CONCLUSION: Necropsy of fatal cases of MI were not significantly different in the presence or absence of severe atherosclerotic narrowing (greater than 70%) of epicardial coronary arteries, suggesting that this factor does not modify the natural history of MI.

A study regarding the anterior cruciate ligament remnant: Differences in balance and postural control between remnant-preserving and remnant-non-preserving patients

Introduction: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. However, quantitative studies on evaluate the postural control influence resulted from the ACL remnant preservation or not are scarce. The aim of this study is to evaluate the postural control of patients submitted to ACL reconstruction with and without preservation of the injured remnant in pre and postoperative periods.MethodsEighteen patients underwent ACL reconstruction and separated into 2 groups according to the preservation or not of the remnant: (I) submitted to ACL reconstruction with preservation of the remnant (10 patients); (II) submitted to ACL reconstruction without preservation of the remnant (8 patients). They were assessed using the Lysholm score and force plate, which evaluated the patient's postural stability for remnant and non-remnant preservation in ACL reconstruction surgery.ResultsGroup I showed statistically significant subjective and objective improvements, both at 3 and 6 months. Additionally, improvement of the Lysholm test at 6 months in Group II was also statistically significant. Furthermore, the results of the Friedman test for the VCOP and VY variables of Group I, with support of the injured side in the force plate, showed a statistically significant difference both for pre and postoperative period at 3 months, compared to the 6-month postoperative period. The variables EAC and VX were statistically different for Group II, considering the preoperative period, 3 and 6 months postoperatively.ConclusionPreserving the ACL remnant in patients with ACL injuries has a positive impact on postural stability during recovery.(AU)

Introducción: El ligamento cruzado anterior (LCA) es el ligamento de la rodilla que se lesiona con mayor frecuencia. Sin embargo, escasean los estudios cuantitativos sobre la evaluación de la influencia del control postural derivada de la preservación, o no, del remanente del LCA. El objetivo de este estudio es evaluar el control postural de los pacientes sometidos a la reconstrucción del LCA, con y sin preservación del remanente lesionado, en los periodos previo y posterior a la cirugía.MétodosDieciocho pacientes sometidos a reconstrucción del LCA separados en 2 grupos, de acuerdo con la preservación o no preservación del remanente: I) sometidos a reconstrucción del LCA con preservación del remanente (10 pacientes), y II) sometidos a reconstrucción del LCA sin preservación del remanente (8 pacientes). Los pacientes fueron evaluados utilizando la puntuación de Lysholm y una placa de aplicación de fuerza, que evaluó la estabilidad postural del paciente para la preservación y no preservación del remanente en la cirugía de reconstrucción del LCA.ResultadosEl grupo I mostró mejoras subjetivas y objetivas estadísticamente significativas, transcurridos 3 y 6 meses. Además, la mejora de la prueba de Lysholm transcurridos 6 meses en el grupo II fue también estadísticamente significativa. Asimismo, los resultados de la prueba de Friedman para las variables VCOP y VY en el grupo I, con apoyo del lado lesionado en la placa de aplicación de fuerza, reflejaron una diferencia estadísticamente significativa en ambos períodos pre y postoperatorio transcurridos 3 meses, en comparación con el período postoperatorio transcurridos 6 meses. Las variables EAC y VX fueron estadísticamente diferentes para el grupo II, considerando el periodo preoperatorio, y los 3 y 6 meses postoperatorios.ConclusiónPreservar el remanente del LCA en los pacientes con lesiones en dicho ligamento tiene un impacto positivo en la estabilidad postural durante la recuperación.(AU)

Survival and predictors of survival in patients with congestive heart failure due to Chagas' cardiomyopathy.

BACKGROUND: The fundamental determinant of the natural history of Chagas' disease is cardiac involvement. METHODS AND RESULTS: We studied 104 male patients with congestive heart failure due to Chagas' disease to estimate the survival distribution function and to evaluate age, functional class (FC), maximal oxygen consumption (VO2max), and ejection fraction (EF) as predictors of survival. Statistical evaluation was performed through univariate (Student's t test and chi 2 test) and multivariate analyses (Cox's regression model). Overall survival was 66% at 1 year, 56% at 3 years, and 48% at 5 years. Ages were not statistically different (P = .9811) between survivor (40.3 +/- 8.7) and nonsurvivor (40.3 +/- 9.4) groups. The ejection fraction(s) were statistically different (P = .0001) between survival (43.6 +/- 9.9) and nonsurvival (30.6 +/- 8.1) groups, as was VO2max (P = .0001) (21.0 +/- 4.7 and 15.0 +/- 4.9, respectively). Most of the surviving patients were in FC II and most of the nonsurvivors were in FC IV (P = .0001). VO2max (P = .0001) and EF (P = .0008) are highly associated with survival time in the multivariate analysis, but FC (P = .0578) is less important. Age (P = .9811) did not influence survival. CONCLUSIONS: We conclude that 50% of the patients with heart failure due to Chagas' disease die in 47 months and that VO2max and EF are important indices of survival in this group.

Determinants of prognosis in 300 episodes of infective endocarditis.

We studied 300 episodes of infective endocarditis in 287 patients to evaluate clinical and laboratory determinants of prognosis by estimating the probability of in-hospital death. The patients' ages ranged from 2 months to 78 (mean 30.76 +/- 16.06) years; 185 (62%) episodes occurred in male and 115 (38%) in female patients. A total of 386 complications occurred in 223 (74%) episodes of endocarditis. The infecting microorganisms were streptococci in 147 episodes, Staphylococcus aureus in 59, Staphylococcus epidermidis in 14, gram-negative bacteria in 16, other gram-positive bacteria in 8, fungi in 4. The causative microorganism was not identified in 52 episodes (negative blood cultures). The underlying cardiac disease was valvular in 119 episodes, congenital in 37, prosthetic heart valve in 69, and others in 6. No previous heart disease was identified in 69 episodes. Surgical treatment was carried out in 102 (34%) patients. Overall, 78 (26%) patients died. The probability of death was estimated with a logistic regression model (stepwise procedure). The model with best prediction included the cardiac status previous to the endocarditis, the causative microorganism, the occurrence of complications, and the blood leukocyte count. The most important variable in predicting in-hospital death was the occurrence of complications, followed by cardiac status (prosthetic valve endocarditis), the infecting microorganism, and leukocyte count. The model underestimated the severity of the disease in patients with acute endocarditis and overestimated in patients with prosthetic valve endocarditis submitted to surgical treatment.

Maximal functional capacity in patients with endomyocardial fibrosis.

We evaluated objectively the cardiocirculatory dysfunction of patients with EMF, and related the functional class (FC-NYHA) to the data obtained by analysis of maximal functional capacity. We studied 55 subjects, divided into three groups: group 1 (G1) 21 (38.1%) normal persons, group 2 (G2) seven (12.7%) patients with EMF who were in FC I or II, and group 3 (G3) 27 (49%) patients in FC III or IV. Maximal oxygen consumption (VO2max) and O2 pulse index (PO2max) were obtained using a Beckman computerized gas analyser. The mean values were significantly different among the three groups. We conclude that the greater the clinical impairment, the greater the alterations that occur in the indices of cardiac function.

Five-year follow-op of the medicine, angioplasty, or surgery study (MASS): A prospective, randomized trial of medical therapy, balloon angioplasty, or bypass surgery for single proximal left anterior descending coronary artery stenosis.

BACKGROUND: Although coronary angioplasty and myocardial bypass surgery are routinely used, there is no conclusive evidence that these interventional methods offer greater benefit than medical therapy alone. This study is intended to evaluate, in a prospective, randomized, and comparative analysis, the benefit of the 3 current therapeutic strategies for patients with stable angina and single proximal left anterior descending coronary artery stenosis. METHODS AND RESULTS: In a single institution, 214 patients with stable angina, normal ventricular function, and severe proximal stenosis (>80%) on the left anterior descending artery were selected for the study. After random assignment, 70 patients were referred to surgical treatment, 72 to angioplasty, and 72 to medical treatment. The primary end points were the occurrence of acute myocardial infarction or death and presence of refractory angina. After a 5-year follow-up, these combined events were reported in only 6 patients referred to surgery as compared with 29 patients treated with angioplasty and 17 patients who only received medical treatment (P=0.001). However, no differences were noted in relation to the occurrence of cardiac-related death in the 3 treatment groups (P=0. 622). No patient assigned to surgery needed repeat operation, whereas 8 patients assigned to angioplasty and 8 patients assigned to medical treatment required surgical bypass after the initial random assignment. Surgery and angioplasty reduced anginal symptoms and stress-induced ischemia considerably. However, all 3 treatments effectively improved limiting angina. CONCLUSIONS: Bypass surgery for single-vessel coronary artery disease is associated with a lower incidence of medium-term and long-term events as well as fewer anginal symptoms than that found in the patients who underwent angioplasty or medical therapy. In this study, coronary angioplasty was only superior to medical strategies in relation to the anginal status. However, the 3 treatment regimens yielded a similar incidence of acute myocardial infarction and death. Such information should be useful when choosing the best therapeutic option for similar patients.

Capacidade funcional máxima e função diastólica em portadores de cardiomiopatia chagásica sem insuficiência cardíaca congestiva / Maximal functinsl capacity and diastolic function in patients with cardiomyopathy due to Chagas'disease without congestive heart failure

OBJETIVO - Identificar disfunçöes cardíacas precoces em pacientes assintomáticos com cardiomiopatia chagásica. MÉTODOS - Foram estudados 38 indivíduos masculinos, sendo o grupo controle constituído de 20 indivíduos sedentários normais e o grupo Chagas de 18 pacientes assintomáticos, portadores da doença de Chagas, com eletrocardiograma alterado e fração de encurtamento (DD) normal ao ecocardiograma. Ambos os grupos foram submetidos à avaliação da capacidade funcional máxima, com medidas do máximo de oxigênio (PO2max), ventilação máxima (VEmax), freqüência cardíaca máxima (FCmax), e limiar anaeróbico do VO2max (LA-VO2). A função diastólica do ventrículo esquerdo foi avaliada pelo ecocardiograma convencional (ondas E e A além da relação E/A). RESULTADOS - Não ocorreram diferenças significativas entre os dois grupos em relação ao DD (p=0,212) e a idade média (p=0,060). Houve diferença significativa (p<0,001) em relação aos parâmetros VO2max, PO2max, VEmax, FCmax, LA-VO2, onda E e relação E/A. Não houve significância (p=0,520) em relação a onda A. CONCLUSÄO - O comprometimento na função ventricular pode contribuir para as diferenças acima mencionadas, como conseqüência de disfunção sistólica e diastólica.

Liver morphology with enphasis on bile ducts changes and survival analysis in mice submitted to multiple Schistosoma mansoni infections and chemotherapy

Numa tentativa de estar o mais próximo possível a pacientes infectados e tratados nas áreas endêmicas de esquistosomose (S. mansoni) e também para obter um período mais longo de seguimento, camundongos foram repetidamente infectado com um número baixo de cercarias. Dados de sobrevivência e variáveis histológicas tais como granuloma esquistosomótico, alteraçöes portais, necrose hepatocelular, regeneraçäo hepática, pigmento esquistosomótico, fibrose periductal e principalmente, alteraçöes dos ductos biliares foram analisados nos animais infectados tratados e näo tratados. Aa terapêutica por oxamniquina ns animais repetidamente infectados prolonga a sobrevivência de maneira singificante (Chi-quadrado 9,24, p = 0,0024), portanto confirmando resultados anteriores com um modelo semelhante mas com um período mais curto de seguimento. Ainda, a mortalidadade decresce rapidamente depois do tratamento, sugerindo uma abrupta reduçäo na gravidade das lesöes hepáticas. O fígado foi anida estudados sob o ponto de vista morfológico imunohistoquímico. Fibrose portal, com um quadro que lembra a fibrose humana do tipo Symmers está presente na fase tardia da infecçäo. As alteraçöes de ductos biliares säo muito próximas daquelas descritas na esquistosomose manônica humana. Antígeno esquistomótico foi observado e, uma célula isolada do revestimento alterado de ductos biliares. A patogênese das alteraçöes ductais e sua possível relaçäo com a infecçäo parasitária e/ou seus antígenos foi discutida