Long-term complications of native valve infective endocarditis in non-addicts. A 15-year follow-up study

OBJECTIVE

To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis.

DESIGN

Cohort study.

SETTING

University-affiliated tertiary medical center.

PATIENTS

One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone.

MEASUREMENTS

Relapse, recurrence, need for late cardiac surgery, and cardiac mortality.

RESULTS

Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years.

CONCLUSIONS

Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).

[Detection of early occlusion of aortocoronary by-passes. Usefulness of a non-angiographic method]

A total of 83 bypasses were studied. Angiographic results demonstrated occlusion in 3 of 24 bypass of internal mammary artery placed in the anterior descending artery, 2 in the right coronary artery, 1 in the posterolateral of the circumflex and 1 in the first diagonal branch, with a total occlusion average of 8.4% within the first 8 days. We found a good correlation between the coronarographic angiograms and the positivity or negativity of the echo-electrocardiographic tests, during atrial pacing. We believe that this simple method could be done routinely in all the patients after coronary surgery, to decide the need of a new coronary angiogram. Furthermore, this study shows that the occlusion of a single coronary bypass does not produce myocardial infarction, detectable by enzymatic measures or by resting EKG. This method also detects the early post-operatory sinus sick syndrome.

Behavioral and neurochemical changes in response to acute stressors: influence of previous chronic exposure to immobilization

The effect of daily (2 h) exposure to immobilization (IMO) for 15 days on the behavioral and neurochemical responses of adult male rats to acute stress caused by 2-h IMO or 2-h tail-shock was studied. The brain areas studied were frontal cortex, hippocampus, hypothalamus, midbrain, and pons plus medulla. Chronic exposure to IMO did not alter noradrenaline (NA), 3-methoxy,4-hydroxyphenyletileneglycol-SO4 (MHPG-SO4), serotonin, or 5-hydroxindoleacetic acid (5-HIAA) concentrations in any brain area as measured approximately 20 h after the last exposure to IMO. Exposure to behavioral tests did not modify neurochemical variables except NA levels in the hypothalamus of nonchronically stressed (control) rats. Both exposure to 2-h IMO or 2-h shock significantly decreased NA levels in hypothalamus and midbrain of nonchronically stressed rats. These decreases in response to the two acute stressors were not observed in chronically stressed rats. However, MHPG-SO4 levels increased to the same extent in control and chronically stressed rats after exposure to the acute stressors. Likewise, increased 5-HIAA concentrations observed in response to acute stressors were similar in control and chronically stressed rats. The inhibition of activity (areas crossed and rearing) in the holeboard caused by acute IMO was less marked in rats previously exposed to the same stressor than in control rats, but the response to shock was similar. In the forced swim test, acute IMO decreased struggling in control rats but tended to increase it in chronically stressed rats. The response to shock followed the same pattern as that to IMO, although it was slight.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous mitral commissurotomy with Inoue balloon. Short-term results. Initial experience at the Ignacio Chavez National Institute of Cardiology]

Percutaneous transvenous mitral commissurotomy (PTMC) using balloon catheters has emerged as an alternative to surgery for patients with mitral stenosis. This report details our recent experience of PTMC with the Inoue balloon in 20 consecutive patients with mitral stenosis from april 2 to july 27, 1991. Mean age was 35.6 +/- 9.5 years. Mitral valve area increased form 1.04 +/- 0.3 to 2.32 +/- 0.5 cm2 (p less than 0.0001). Mitral valve gradient decreased from 19.2 +/- 8.8 to 6.6 +/- 2.3 mmHg. (p less than 0.0001). Two patients developed mitral regurgitation greater than 2+/4 after the procedure. In none the residual left to right shunt was greater than 1.2L. There was no mortality. We conclude that in selected patients, excellent results are obtained PMTC with the Inoue balloon. Complications are minimal.

[A descriptive epidemiological study of ulcerative colitis in a community hospital (1985-1989)]

BACKGROUND

The incidence of ulcerative colitis (UC) shows a marked geographical variation. It is high in Anglo-Saxon and Scandinavian countries, while in Mediterranean countries the available data on its epidemiological features are few. Spain is not an exception.

METHODS

The new cases of UC diagnosed during the period 1985-1989 in the Hospital de Sabadell (a reference center of an area with a markedly industrial population of 343924) were retrospectively evaluated. The definitive diagnosis of UC required a negative fecal microbiological study and findings in colonoscopy and biopsy consistent with UC.

RESULTS

During the study period 68 new cases of UC were diagnosed, representing a mean yearly incidence of 3.95/10(5) population, and 5.26/10(5) considering only the adult population (age greater than 14 years). No significant differences were found (p greater than 0.05) in the sex and age distributions, although the male/female ratio was 1.06. In 84% of cases UC was limited to the rectum and/or distal colon, with a low frequency of pancolonic forms (5%). In 70% of patients UC was classified as a low severity disease.

CONCLUSIONS

Although the estimation of incidence only from hospital cases underestimates the true incidence, and also considering the limitation of comparing results of studies from several time periods, the incidence of UC in our area is the highest one reported to the present time in Spain and Southern Europe. Nevertheless, it is lower than that in most Northern European countries.

Influence of various acute stressors on the activity of adult male rats in a holeboard and in the forced swim test

The effects of various acute stressors on the activity of adult male rats in a holeboard and in the forced swim test were studied. When tested immediately or 24 h after 1 h exposure to noise, restraint in tubes or tail shock, no changes in either defecation rate or activity in the holeboard were observed. In contrast, immediately after 1 h immobilization in wood-boards, a reduction of the number of areas crossed and the number of head-dips was found. The inhibitory effect of immobilization on head-dips persisted 24 h later. The behavior of the rats in the forced swim test was classified into three categories: struggling, mild swim and immobility. The changes in behavior were critically dependent on the type of stressor, and more specifically on its intensity, that was evaluated with three different physiological parameters (serum prolactin, corticosterone and glucose levels). Thus, if tested immediately after stress, noise did not alter the response of the rats, restraint in tubes and tail shock-reduced immobility, and the latter stressor increased mild swim. In the second experiment, immobilization in wood-boards reduced struggling. Twenty-four hours after stress, noise, restraint in tubes or tail shock were without effect, but immobilized rats showed increased immobility and reduced mild swim activity. The present data clearly indicate that behavior of rats in a holeboard and in a forced swim situation are not related, and that acute stress could have a differential effect on the various categories of behavior in a forced swim situation.

The serum glucose response to acute stress is sensitive to the intensity of the stressor and to habituation

The reliability of serum glucose concentrations as an index of habituation to chronic stress was evaluated in adult male rats. The glucose response to immobilization was attenuated by six days of previous chronic exposure to the same stressor, the degree of reduction being related to the duration (15 min, 1 hr or 4 hr) of the daily exposure to immobilization. In another experiment, three groups of rats were exposed to one of three stressors (handling plus change of room, restraint in tubes, or immobilization by wood boards), 1 hr daily for 27 days. On day 28, when faced with the same acute stressor to which they were chronically exposed, the rats showed a consistent reduction in glucose response, regardless of the type of stressor used. In addition, in stress-naive rats serum glucose levels were related to the intensity of the stressor as assessed by three independent measures (food intake, body weight changes, and adrenal weight after chronic exposure to the stressor). These data indicate that, under appropriate conditions, glucose levels can be a good index of both the intensity of acute stress experienced by the rats and their habituation to repeated stress.

[Diagnosis of tumor invasion of the cartilage in neoplasm of the larynx using computed tomography]

The demonstration of the tumoral invasion of the cartilaginous structure of the larynx is a fact that contraindicates any conservative treatment, either surgical or radiotherapeutic. The usual methods of clinical exploration, such as direct or indirect laryngoscopy or fiberoptic laryngoscopy are not very useful, as well as conventional radiology which presents little sensitivity to defect tumoral invasion. It has been communicated previously that computerised tomography (CT) is more sensitive. In our evaluation of these different diagnostic methods, we present a series of 51 patients with laryngeal cancer at different stages in a hom studies prior to surgery using computerised tomography (CT) have been realised. We evaluate the efficacy of his diagnostic method in the tumoral invasion of the laryngeal backbone. Results have been analysed, demonstrating that this method is superior to other techniques used.

[Role of intraoperative echo-Doppler color echocardiography in cardiac surgery. Preliminary study]

Intraoperative echocardiography with Doppler color flow imaging technique can provide the surgeon with an immediate and direct assessment of cardiac anatomy and function. To determine the utility of this recent technique, we have examined 15 patients pre, per, and postoperatively with Doppler color flow imaging. The intraoperative study was performed before and after cardiopulmonary bypass. A sterile transducer was placed directly on the epicardial surface of the heart, and multiple views were recorded. Intraoperative echocardiography with Doppler color flow imaging technique demonstrated excellent correlation with preoperative and postoperative findings, allowing an immediate evaluation of the surgical results. These preliminary results suggest that intraoperative Doppler color flow imaging technique is a valuable adjunct in heart surgery. It is particularly useful in valve repair, and in surgical repair of congenital heart disease.

[Intravenous streptokinase in acute myocardial infarction. A Mexican multicentric study]

To evaluate the benefits of intravenous streptokinase (SQIV) in acute myocardial infarction (AMI), we joined a group of ten Mexican university hospitals, that were coordinated by the National Institute of Cardiology of Mexico. We included patients less than 70 years of age admitted to the hospital with less than 6 hours from the onset of chest pain during their first myocardial infarction. All patients had ST segment elevation of 1.5 mm or more, and none had contraindication for SQIV. They received 1.5 millions of SQIV in one hour. Reperfusion criteria included absence of pain, ST segment reduction and a rapid rise and fall of enzyme levels. Angiographic criterion for reperfusion was the permeability of the affected coronary vessel. Of 66 patients studied, 57 (86%) had clinical reperfusion; of the 24 available angiographic studies, 92% demonstrated reperfusion. Eight (12%) of the patients had minor complications and 7 (10%) had serious complications. There were 0 deaths. We concluded that SQIV is a useful therapeutic procedure, easy to perform in general hospitals.

Simultaneous purification and characterization of aspartate aminotransferase isoenzymes from chicken liver

Cytosolic and mitochondrial isoenzymes of aspartate aminotransferase (EC 2.6.1.1) were purified to homogeneity from chicken liver, without previous fractionation of the subcellular components. The procedure includes initial heat treatment and ammonium sulfate fractionation. The two isoenzymes can then be separated by a DEAE-Sepharose chromatography using a linear gradient of L-aspartate (reaction substrate). The separated fractions can be further purified by a parallel step with HA-Ultrogel prior to octyl-Sepharose (c-AAT) and CM-Sepharose (m-AAT) chromatographies. Michaelis constants, pI values, inhibition by adipate and subforms generation with time were studied for both isoenzymes.

A kinetic method for quantification of aspartate aminotransferase isoenzymes

A spectrophotometric assay is proposed to determine the levels of aspartate aminotransferase (AAT) isoenzymes from chicken liver by a steady-state kinetic method which depends on the differential inhibition of these isoenzyme forms by high concentrations of substrate 2-oxoglutarate at pH 6.2. The use of a standard curve permits the determination of the percentage of chicken liver c-AAT and m-AAT isoenzymes. This method yields results in good correlation with those achieved by different extent adipate inhibition and by differential centrifugation.

Intramitochondrial location and some characteristics of chicken liver aspartate aminotransferase

Chicken liver mitochondrial aspartate aminotransferase was found to be located in the intermembrane space and bound to the inner mitochondrial membrane. Purification of two mitochondrial fractions containing aspartate aminotransferase activity was performed. Both fractions showed similar chromatographic behaviour and identical isoelectric point and molecular weight values. There were no significant differences in the general kinetic mechanism, Km values, substrates inhibition and effect of various anions on the activity of mitochondrial aspartate aminotransferase purified from both fractions.