Marginal and Internal Misfit of Occlusal Veneers Made in Resin-matrix Ceramics

Objective

Considering that misfit is a significant predictor of the clinical success of indirect restorations, the objective of this study was to evaluate the marginal and internal misfit of two computer-aided design and manufacturing (CAD/CAM) RMC ceramic materials used as occlusal veneers (OVs) of different thicknesses.

Methods and Materials

A CAD model of a mandibular first molar was obtained and OV preparations 0.5-, 1.0-, and 1.5-mm thick were modeled and milled in two different materials (n=10/group): resin nanoceramic (RNC) and polymer-infiltrated ceramic network (PICN). Using the same CAD model, tooth preparations were milled in fiber-reinforced epoxy resin (n=20/thickness). The marginal and internal misfit of the restorations was assessed by X-ray microtomography. The measurements of the marginal gap (MG) and absolute marginal discrepancy were performed in two locations on each slice, whereas internal gap (IG) measurements were performed at ten locations on each slice. The data obtained were analyzed using two-way analysis of variance and Tukey post-hoc tests (α=0.05).

Results

No significant effect was attributable to the material type or material–thickness interaction for the MG, absolute marginal discrepancy (AMD), or IG (p>0.05). However, the thickness significantly affected the IG of the restorations (p<0.05). CAD/CAM RNC and PICN systems presented similar MG and AMD for OVs 0.5-, 1.0-, and 1.5-mm thick. However, the IG varied between thicknesses.

Ten-year survival of patients undergoing coronary angioplasty with first-generation sirolimus-eluting stents and bare-metal stents

INTRODUCTION

Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients' survival has been the subject of debate.

OBJECTIVE

To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS.

METHODS

In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database.

RESULTS

All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p<0.001), greater stent length (18.50±8.2 vs. 15.96±6.10 mm; p<0.001) and higher number of stents per patient (1.95 vs. 1.46, p<0.001) in the SES group. Overall five- and 10-year all-cause mortality was 9.6% (n=110) and 22.7% (n=272), respectively. The adjusted HR for 10-year mortality in patients undergoing PCI with SES was 0.74 (95% CI 0.58-0.94; p=0.013), corresponding to a relative risk reduction of 19.8%. Other than PCI with BMS, older age, chronic kidney disease, chronic obstructive pulmonary disease and lower ejection fraction were independent predictors of 10-year mortality.

CONCLUSION

To date, this is the longest follow-up study ever showing a potential survival benefit of first-generation sirolimus-eluting stents versus bare-metal stents, supporting prior observations on their sustained efficacy and safety relative to contemporary BMS.

Measurement of the absolute gamma emission intensities from the decay of Th-229 in equilibrium with progeny

There are few long-lived radionuclides yielding high intensity gamma-rays emission with energies ranging from 100 keV to 500 keV that can be applied as radioactive gamma standard to calibrate HPGe detectors. Furthermore, this energy range represents the main emitted energies of the majority of radionuclides used in nuclear medicine. The Brazilian National Laboratory for Ionizing Radiation Metrology (LNMRI/IRD/CNEN) has attempted to identify radionuclides that have the potential to be used as a calibration source due to their long half-life as well as their emission spectrum. Hence, LNMRI promotes standardization studies of gamma-emitting radionuclides that meet these criteria on order to disseminate them. Thorium-229, with its well-defined energies and relatively high intensities, is one such candidate radionuclide for the energy and full-energy peak efficiency calibration of high-purity gamma spectrometers. Thorium-229 was standardized by the method of 4παβ(LS)-γ(NaI(Tl)) live timed anticoincidence counting. The emission intensities of gamma-rays associated with the decay of ²²⁹Th have been determined by HPGe gamma ray spectrometry with accuracy and precision. The results are in agreement with current literature data.

Anesthesia using microcannula and sharp needle in upper blepharoplasty: A randomized, double-blind clinical trial evaluating pain, bruising, and ecchymoses

INTRODUCTION

With the emergence of blunt-tipped microcannulas, there is a hypothesis that these could cause less damage and reduce pain as compared to conventional sharp needles in eyelid surgery. The purpose is to determine whether an 18G blunt-tipped cannula can be better than a 26G needle.

METHODS

This prospective, observer-blinded, randomized clinical trial was conducted from June 2017 to December 2018. Sixty-eight patients were randomized to receive local anesthesia injections for upper blepharoplasty. Infiltration was performed by using a 26-gauge sharp needle on one side and on the other side, infiltration was performed by using an 18-gauge stainless-steel blunt-tipped microcannula. A numeric rating scale (NRS) from 0 to 10 was used to blindly assess pain in patients receiving anesthesia injections with both needle types. Photographs of the eyelids of each patient were taken in five different periods and used by three blinded observers to identify bruise or ecchymoses.

RESULTS

A total of 136 eyelid operations were performed. There was no statistically significant difference when both groups were compared; however, the average score of pain was higher in patients taking the infiltration through the needle (2.85 versus 2.50). Regarding the evaluation of bruising and ecchymoses, the results showed that, in the five periods evaluated, there was no statistical difference in bruising and ecchymosis in the eyelids when taking the infiltration through a sharp needle when compared with that of the eyelids taking infiltration through a (blunt-tipped) microcannula.

CONCLUSION

The evaluation of the blunt-tipped microcannula showed a lower pain score mean than that obtained for the sharp needle (2.5 versus 2.85) (p > 0.05). There was no statistically significant difference in the bruising and ecchymosis courses.

Determining the probability of locating peaks using computerized peak-location methods in gamma-ray spectra as a function of the relative peak-area uncertainty

The probabilities of locating peaks with a high relative peak-area uncertainty were determined empirically with nine types of peak-location software used in laboratories engaged in gamma-ray spectrometry measurements. It was found that it is not possible to locate peaks with a probability of 0.95, when they have a relative peak-area uncertainty in excess of 50%. Locating peaks at these relatively high peak-area uncertainties with a probability greater than 0.95 is only possible in the library-driven mode, where the peak positions are supposed a-priori. The deficiencies of the library-driven mode and the possibilities to improve the probabilities of locating peaks are briefly discussed.

Late results (>10 years) of intracoronary beta brachytherapy for diffuse in-stent restenosis

INTRODUCTION

Until the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES.

OBJECTIVE

To assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis.

METHODS

This single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43-77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta-CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization.

RESULTS

In all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients).

CONCLUSIONS

Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation.

Relevant aspects of radiation protection in oil and gas well logging

Radiation sources have being widely used in industrial applications, but their inappropriate use presents a large potential for hazards to human health and the environment. These hazards can be minimised by development of specific radiation protection rules and adequate procedures for the handling, use and storage of radiation sources, which should be established in a national normative framework. Recently, due to discovery of new oil and gas reservoirs on the Brazilian continental shelf, especially in deep water and the pre-salt layer, there has been a large and rapid increase in the use of radiation sources for well logging. Generic radiation protection regulations have been used for licensing the use of radiation sources for well logging, but these are not comprehensive or technically suitable for this purpose. Therefore it is necessary to establish specific Brazilian safety regulations for this purpose. In this work, an assessment is presented of the relevant radiation protection aspects of nuclear well logging not covered by generic regulations, with the aim of contributing to the future development of specific safety regulations for the licensing of radioactive facilities for oil and gas well logging in Brazil. The conclusions of this work relate to four areas, which include the specific requirements to control (1) radiation sources, (2) radiation survey meters and (3) access to radiation workplaces and (4) to control and identify the workers who are occupationally exposed.

57Co half-life determination

The National Laboratory for Metrology of Ionizing Radiation (LNMRI)/Brazil participated in the last (57)Co activity measurement comparison organized by IAEA, in 2008. This was made in order to realize primary standardization of this radionuclide and to reduce the measuring uncertainties in the laboratory. Additionally, one sample with 2.6g was taken from the IAEA master solution of (57)Co and was prepared to be used in the measurement of the radionuclide's half-life in an ionization chamber system. The (57)Co half-life was measured to be 271.82 (17) days.

Interleukin-6 expression and gene polymorphism are associated with severity of periodontal disease in a sample of Brazilian individuals

Interleukin (IL)-6 is an inflammatory mediator involved in bone resorption. G/C polymorphism at position -174 of the IL-6 gene has been reported to influence IL-6 expression, with the G allele associated with higher expression levels. The aims of this study were to investigate the expression of IL-6 as well as the incidence of IL-6 (-174) gene polymorphism and their correlation to the severity of periodontitis in Brazilians. Peripheral blood mononuclear cells were collected from 12 non-smoker individuals with periodontitis for evaluation of IL-6 expression using flow cytometry. We observed a positive correlation between the mean clinical attachment loss and intensity of expression of IL-6, in which the greater the attachment loss, the higher the expression of IL-6 (P=0 x 007, R2=0 x 52). Also, patients with severe periodontitis displayed a higher intensity of IL-6 expression compared to moderate periodontitis (P=0 x 04). To determine the occurrence of IL-6 gene polymorphism, DNA was obtained from oral swabs of 209 Brazilian individuals with and without periodontitis. Polymerase chain reaction, restriction endonuclease digestion and electrophoresis were performed, allowing for detection of the IL-6 (-174) polymorphism. We observed that non-smokers with moderate periodontitis (P=0 x 05) and control (P=0 x 04) groups displayed a higher incidence of the G genotype when compared to severe periodontitis. This suggests that the G genotype may represent a protective role in severity of periodontitis. Thus, the increased expression of IL-6 and IL-6 (-174) polymorphism are associated with periodontal disease severity in Brazilian individuals.

The Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) Trial

In the main Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) report, we investigated outcomes in 15 245 high-risk hypertensive subjects treated with valsartan- or amlodipine-based regimens. In this report, we analyzed outcomes in 7080 patients (46.4%) who, at the end of the initial drug adjustment period (6 months), remained on monotherapy. Baseline characteristics were similar in the valsartan (N=3263) and amlodipine (N=3817) groups. Time on monotherapy was 3.2 years (78% of treatment exposure time). The average in-trial blood pressure was similar in both groups. Event rates in the monotherapy group were 16% to 39% lower than in the main VALUE trial. In the first analysis, we censored patients when they discontinued monotherapy ("censored"); in the second, we counted events regardless of subsequent therapy (intention-to-treat principle). We also assessed the impact of duration of monotherapy on outcomes. No difference was found in primary composite cardiac end points, strokes, myocardial infarctions, and all-cause deaths with both analyses. Heart failure in the valsartan group was lower both in the censored and intention-to-treat analyses (hazard ratios: 0.63, P=0.004 and 0.78, P=0.045, respectively). Longer duration of monotherapy amplified between-group differences in heart failure. New-onset diabetes was lower in the valsartan group with both analyses (odds ratios: 0.78, P=0.012 and 0.82, P=0.034). Thus, despite lower absolute event rates in monotherapy patients, the relative risks of heart failure and new-onset diabetes favored valsartan. Moreover, these findings support the feasibility of comparative prospective trials in lower-risk hypertensive patients.

Metabolic score--a simple risk marker in non-ST elevation acute coronary syndromes

BACKGROUND

Atherothrombotic coronary artery disease is increasingly recognized as part of a systemic metabolic disorder. However, little is known about the significance of metabolic dysfunction in the setting of acute coronary syndrome.

OBJECTIVE

Our aim was to assess the prognostic implications of markers of metabolic dysfunction at hospital admission obesity (BMI > 30), previous history of hypertension, admission glucose > 128 mg/dl, triglycerides > 150 mg/dl, and HDL cholesterol < 40 mg/dl for men, or < 50 mg for women--in patients with non-ST elevation acute coronary syndromes (ACS).

METHODS

A total of 303 consecutive patients admitted to the CCU with ACS were included in the study. Mean age was 63 +/- 10 years, and 86% were male. The primary end-point was a composite of death or non-fatal acute myocardial infarction (MI) at one-year follow-up. Each marker was assigned one point, and a metabolic score (MetScore) was calculated for each individual patient by adding together the number of markers present at hospital admission. Three groups were considered: group 1 (MetScore 0) with 0 markers (n = 30); group 2 (MetScore 1 to 3) with 1 to 3 markers (n = 222); and group 3 (MetScore 4 to 5) with 4 to 5 markers (n = 51).

RESULTS

The cumulative incidence of death or MI was 14.5%. We found a statistically significant relation between MetScore and outcome at one-year follow-up. The event rate was 3.3% in the MetScore 0 group, 13.9% in the MetScore 1 to 3 group and 23.5% in the MetScore 4 to 5 group (p = 0.0114). MetScore was an independent predictor of death or MI at one year, with a 2.3-fold risk increase (95% CI: 1.32-4.01; p = 0.003) from one group to the next. Other variables identified as independent predictors of outcome were advanced age, Killip class, ST-segment depression and previous CABG. The incidence of the primary end-point in diabetic patients without significant metabolic dysfunction and non-diabetic patients with SMD was similar (21.2% vs. 22.7%; p = NS).

CONCLUSION

Assessment of markers of metabolic dysfunction on admission in patients with non-ST elevation acute coronary syndromes, adds important prognostic information to conventional clinical, ECG and risk stratification markers and could prove useful in establishing secondary prevention strategies.

Natural infection by Giardia sp. and Cryptosporidium sp. in dairy goats, associated with possible risk factors of the studied properties

Visits were made to six farms raising dairy goats located in the mountain region of the state of Rio de Janeiro, Brazil, seeking to identify parasitism by Giardia sp. and Cryptosporidium sp. During the visits, fecal samples were collected from approximately 10% of the stock of each property. A questionnaire was given to the keepers on each property to obtain data for epidemiological analysis. A total of 105 fecal samples was collected, 56 from adult animals (over 12 months of age) and 49 from juvenile animals (less than 12 months). The fecal material was processed and subjected to the centrifuge-flotation technique and to staining with safranine-methylene blue. Protozoans of the genus Cryptosporidium were found at two properties, where the hygiene conditions of the installations were considered average and the stalls were made of wood slats raised from the ground. A total of five (4.8%) of the samples was found to be positive for the presence of this protozoan, all from juvenile animals. Cysts of the genus Giardia were found at two properties. Of the 105 samples analyzed, the protozoan was detected in 15 (14.3%), all in juvenile animals, and animals in the age range of 1-3 months had significantly more infections. Age, sanitary condition of the stalls and stalls made of wood slats and raised from the ground, can be pointed out as possible risk factors for infection by Giardia sp. and Cryptosporidium sp. The study reports for the first time the occurrence of Cryptosporidium sp. and Giardia sp. in goats in the state of Rio de Janeiro.

Comparison between natural infection by Cryptosporidium sp., Giardia sp. in dogs in two living situations in the West Zone of the municipality of Rio de Janeiro

In order to compare natural infection by Cyptosporidium sp. and Giardia sp. in clinically healthy dogs living in two situations (animal shelter and household pets), we conducted 166 faecal exams using the technique of centrifugation-flotation in a sugar-saturated solution. Of the faecal samples, 94 came from shelter dogs and 72 from house pets. Eighty-two (49.4%) contained parasite eggs, cysts or oocysts. Of these, four (2.41%) contained Cryptosporidium sp. oocysts and 52 (31.33%) contained Giardia sp. cysts. There was no statistically significant difference between the origin of the dogs and Cryptosporidium sp. infection. Infection by Cryptosporidium sp. was not associated with the living conditions and sex. With respect to Giardia sp., we observed a statistically significant difference (p < 0.001) between the shelter dogs (45%) and the household pets 12.3%. There was no association of infection by Giardia sp. with age or sex.

Cholesterol pericarditis--relapsing pericardial effusion in a patient with rheumatoid arthritis

Cholesterol pericarditis is an uncommon form of pericardial disease, of unknown pathophysiology, that is characterized by chronic relapsing, usually large, pericardial effusions that are distinctive due to a high level of cholesterol. Usually it is idiopathic, but it can be associated with various systemic diseases such as hypothyroidism, rheumatoid arthritis and tuberculosis, among others. Its clinical course is usually indolent and complications such as cardiac tamponade and chronic constrictive pericarditis are relatively rare. However, the need for surgery for complete treatment has been reported in at least 10 % of cases. When rheumatoid arthritis is the underlying cause, this outcome is more frequent among those with an acute episode of pericarditis during the course of the disease. We report the case of a 61-year-old female rheumatoid arthritis patient, who presented with heart failure due to a large pericardial effusion and was successfully treated by a surgical approach.

Implantable cardioverter-defibrillators in hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy is a genetic disease inherited as an autosomal dominant trait associated with risk of sudden death. The majority of cases of sudden death occur in young adults with no or few symptoms, which underlines the importance of risk stratification as a basis for selecting a therapeutic strategy. Implantable cardioverter-defibrillators are indicated in patients resuscitated following cardiac arrest, and those with sustained ventricular tachycardia or two or more risk factors identified in non-invasive tests.

AIM

The aim of this study was to determine the number of appropriate therapies (anti-tachycardia pacing and defibrillation) and the risk factors, or association of risk factors, that predict therapies in patients with hypertrophic cardiomyopathy and an implantable cardioverter-defibrillator.

METHODS

We studied 17 consecutive patients with hypertrophic cardiomyopathy and cardioverter-defibrillators implanted between December 1992 and June 2003. The following risk factors were analyzed: 1) previous cardiac arrest or sustained ventricular tachycardia; 2) family history of sudden cardiac death; 3) high-risk genetic mutations; 4) syncope; 5) non-sustained ventricular tachycardia; 6) hypotensive response to exercise; and 7) marked left ventricular hypertrophy. Appropriate therapies were determined and the predictive value of the different sudden death risk stratification parameters was analyzed.

RESULTS

During a mean follow-up of 40 +/- 29 months, 7 patients (41%) received a total of 293 appropriate therapies. Of the 9 patients with previous cardiac arrest or ventricular tachycardia, 4 received appropriate therapies. In the remaining 8 patients, with implantable cardioverter-defibrillators for primary prevention, 3 received appropriate therapies. Family history of sudden death was associated with a positive predictive value of 25% for appropriate therapies, 40% for syncope and 50% for non-sustained ventricular tachycardia. The presence of any two risk factors was associated with a positive predictive value of 33% and the presence of three factors with 100%.

CONCLUSION

In this group of patients, considered to be at high risk for sudden cardiac death, a considerable percentage had ventricular tachycardias that were correctly identified and treated by the implantable cardioverter-defibrillator. The percentage of patients with appropriate therapies was slightly higher in the group who had a cardioverter-defibrillator for secondary prevention of sudden death (aborted sudden death or sustained ventricular tachycardia). In patients with an implantable cardioverter-defibrillator for primary prevention, non-sustained ventricular tachycardia was the risk factor with the highest predictive value. An association of risk factors was also predictive of arrhythmic events.

Three-Year Outcome After Coronary Stenting Versus Bypass Surgery for the Treatment of Multivessel Disease

Background— The primary results of Arterial Revascularization Therapy Study reported a greater need for repeated revascularization after percutaneous coronary intervention with stenting (PCI). However, PCI was less expensive than coronary artery bypass grafting (CABG) and offered the same degree of protection against death, stroke, and myocardial infarction.

Methods and Results— Patients with multivessel disease (n=1205) were randomly assigned to either CABG or PCI and followed up for up to 3 years. Survival rates without stroke or myocardial infarction were similar in each group at 1 year and 3 years (90.5% versus 91.4% for PCI versus CABG at 1 year and 87.2% versus 88.4% for PCI versus CABG at 3 years). However, the respective repeat revascularization rates were 21.2% and 26.7% at 1 and 3 years in patients allocated to PCI, compared with 3.8% and 6.6% in patients allocated to CABG ( P <0.0001). Diabetes ( P <0.0009) and maximal pressure for stent deployment ( P <0.002) are the strongest independent predictors of events at 3 years after PCI, whereas left anterior descending coronary artery grafting ( P <0.006) is the best predictor of event-free survival at 3 years after CABG. The incremental cost of surgery compared with PCI for an event-free patient was 19 257 at 1 year but decreased to 10 492 at 3 years. It remained at 142 391 at 3 years when revascularization procedures were excluded in the efficacy end point, however.

Conclusions— Three-year survival rates without stroke and myocardial infarction are identical in both groups, and the cost/benefit ratio of stenting is determined primarily by the increasing need for revascularization in the PCI group.

Percutaneous ablation of atrial fibrillation: assessment of outcomes at 1-year follow-up

OBJECTIVE

Current non-pharmacologic treatment strategies for atrial fibrillation (AF) involve discrete ablation of ectopic foci or isolation of the pulmonary vein (PV) ostia, which have been implicated in the genesis of this rhythm disorder. The aim of this study was to determine intermediate and long-term outcomes after percutaneous AF ablation and predictors of successful treatment.

POPULATION AND METHODS

We studied 29 consecutive patients (72% male, mean age 52.3 +/- 13 years) who underwent percutaneous ablation of AF refractory to antiarrhythmic drug therapy. AF was idiopathic in 22 patients and the remaining 7 patients were hypertensive. Six patients had permanent AF and the others had recurrent paroxysmal AF (with at least 1 episode a week). Left atrial size was 40.3 +/- 6.1 mm. A total of 35 ablation procedures were performed, 12 using the focal ablation technique and 23 by PV isolation. Six patients underwent a redo procedure. Patients were evaluated at 1-year follow-up (symptoms, medication, ECG and Holter monitoring). Predictors of successful treatment were identified among baseline clinical variables (age, gender, hypertension), LA size, AF sub-type, ablation technique, and number of isolated PV, using multivariable logistic regression.

RESULTS

At 1-year follow-up, 20 patients presented sinus rhythm (69%), of whom 7 were taking antiarrhythmic drugs and remained free of AF relapse. Out of the total of 35 procedures, 2 immediate complications occurred: pericardial tamponade in one patient and right phrenic nerve palsy in another. Predictors of long-term success were absence of a prior history of hypertension and isolation of at least three PV (p = 0.01 for both independent predictors).

CONCLUSION

Two out of three patients who underwent AF ablation presented sinus rhythm one year after the intervention. Isolation of at least three PV and idiopathic etiology are independent predictors of successful treatment.

Direct stenting with the Bx VELOCITY balloon-expandable stent mounted on the Raptor rapid exchange delivery system versus predilatation in a European randomized Trial: the VELVET trial

AIMS

This study examined the six-month angiographic results of direct coronary stenting, and compared the nine-month safety, efficacy and cost of this strategy versus stenting after balloon predilatation.

METHODS

In phase I of VELVET, 122 patients (mean age = 62.3 +/- 10.1 years, 77% male, 11% with diabetes) with angina pectoris or myocardial ischemia resulting from a single de novo 51% to 95% coronary stenosis underwent direct stenting. The endpoints of phase I included angiographic findings and rates of major adverse cardiac events up to six months of follow-up. In phase II, 401 patients (mean age = 61.3 +/- 10.8 years, 79% male, 16% with diabetes) with angina pectoris or documented myocardial ischemia resulting from single or multiple, de novo or restenotic, coronary lesions were randomized between direct stenting and stenting after predilatation. The immediate angiographic results, and clinical outcomes and costs associated with the two treatment strategies up to nine months of follow-up were compared.

RESULTS

In phase I the mean diameter stenosis immediately before and after the procedure, and at six months was 61.7+/-9.4%, 13.5+/-6.3%, and 33.6+/-16.2%, respectively. The six-month binary restenosis rate was 11%. The overall rate of major adverse cardiac events, including two non-cardiac deaths, was 9.8%. In phase II, the success rates of the intended delivery strategies were 87.9% and 97.9% for direct stenting and predilatation, respectively (p < 0.001), while the procedural success rates were similar (93.9% vs 96.5%). Over a follow-up period of nine months, major adverse cardiac events rates were 12.0% and 10.9% in patients randomized to direct stenting and predilatation, respectively (non-significant). Analyses of the costs incurred up to nine months in each treatment group revealed a mean saving of e362 per patient in favor of the direct stenting strategy (non-significant).

CONCLUSIONS

Compared with a strategy of stenting preceded by balloon dilatation, direct stenting was associated with an equivalent procedural success rate, equivalent clinical results up to nine months of follow-up, and a reduction in procedural and in-hospital costs (p < 0.0001 and p < 0.001, respectively), that was no longer significant after nine months.

[Diagnosis of meningitis with reagent strips]

OBJECTIVE: To determine the usefulness of reagent strips in the evaluation of pleocytosis, cerebrospinal fluid glucose and protein levels for early and rapid diagnosis of meningitis in children. METHODS: We included cerebrospinal fluid samples of 164 children admitted to the outpatient clinic of Communicable Diseases of the General Pediatric Center (Fundação Hospitalar do Estado de Minas Gerais, CGP-FHEMIG) during the daytime hours from May of 1997 to May 1999, and who presented with clinical suspicion of meningitis. Patients ranged in age from one month to 12 years (median 12 months). Results from the cytological and biochemical assay (cellularity, cerebrospinal fluid glucose and protein levels) were obtained from 154 patients. These results were subsequently compared with the reaction of cerebrospinal fluid in reagent strips. RESULTS: The cytological and biochemical assay identified 43 cases of probable bacterial meningitis, 19 of probable viral meningitis, and 83 with no alterations. According to the reagent strips, there were 41 cases of probable bacterial meningitis, 2 of probable viral meningitis, and 71 with no alterations. By comparing the results of reagent strips and those of the cytological and biochemical assay, we obtained values for sensitivity, specificity, positive and negative predictive values, and accuracy (respectively 90.7; 98.1; 95.1; 96.4; and 96.1). Statistical analysis using McNemer test did not indicate significant differences between the two methods in the diagnosis of bacterial meningitis (P=0.68). Kappa statistics indicated a high level of agreement between the tests (P<0.0001). CONCLUSIONS: Our results suggest that reagent strips may be a useful additional resource in the diagnosis of bacterial meningitis, especially when it is difficult to collect a sufficient amount of cerebrospinal fluid or to indicate the initial treatment.

[Coronary angiography in the outpatient with angina pectoris]

Coronary angiography remains the only definitive diagnostic procedure to assess the severity and extension of coronary artery disease. We discuss some technical aspects and the place of angiography in the risk stratification of the coronary patient comparing conservative and invasive strategies. It is suggested that a progressively more important role will be played by the general practitioner regarding indication, interpretation and therapeutic decision, sharing responsibilities with the cardiologist and the patient. With increased facilities for coronary angiography and increased ad hoc angioplasties, observed at present, the GP should also be responsible for proper selection of the reference cardiologists and hospitals.

[Acute myocardial infarct in a young cocaine user]

In patients less than 40 years of age, acute myocardial infarction (AMI) has special clinical and pathophysiologic characteristics. Its prevalence varies between 5 and 10%. In such patients, AMI associated with chronic cocaine abuse has a non-negligible prevalence of 6%. The purpose of this report is to describe the case of a 24-year old male patient with smoking habits and chronic abuse of cocaine and hallucinogenic drugs. This patient developed clinical, enzymatic and electrocardiographic criteria of anterior AMI, two hours after the ingestion of an LSD-like hallucinogenic drug. The coronary angiography revealed a critical stenosis of the medium segment of the left anterior descendent artery, and a pre-stenotic aneurysmatic dilatation. In order to determine the etiology of the aneurysm, various laboratory and histologic tests were performed. The results of these were normal. We review the pathophysiology, clinical manifestations and prognosis of cocaine-associated AMI.

[The determination of the mitral valve area after commissurotomy. A comparison of 2 echocardiographic methods]

OBJECTIVE

To compare the mitral valvular area obtained by two-dimensional echocardiography (2DMVA) to that obtained by Doppler through pressure half-time, (T1/2P) method (DMVA) in patients submitted to open or closed commissurotomy.

POPULATION

Data were obtained from 53 patients, 44 females and 9 males who ranged in age from 19 to 63 years (mean = 40.4 +/- 8) submitted to open commissurotomy (group A) or closed procedure (group F). The time from surgery to Echo ranged from 10 to 100 months (mean = 63 +/- 26). Ther were twenty one patients, in group A and 32 in group F.

METHODS

All the patients underwent two-dimensional echocardiography and continuous-wave doppler, guided by image and sound, so that the maximum velocity was located, using a Diasonics DRF 300 machine equipped with a combined echo-Doppler 3.5 mHz transducer. The mitral valve was visualized in short axis view the 2D mitral valve area was measured as the planimetered area along the inner border of the smallest orifice, while scanning through the short axis. Continuous-wave Doppler recordings were performed at 50 mm/s. The pressure half-time was measured as the interval between maximum velocity and maximum velocity/1.4. The valvular area (DMVA) was obtained by the expression 220/T1/2p. Maximum velocity (VMax) of mitral flux and the prevalence of significant mitral regurgitation (> = 2) were also compared in groups A and F. The relationship between 2DMVA and DMVA were compared by simple linear regression analysis and the other parameters by the t test and by chi-squared analysis.

RESULTS

2DMVA in the total patients was 2.26 +/- 0.59 and the DMVA 2.31 +/- 0.76 (NS). There were no significant difference between groups A e F concerning: VMax = 162.48 +/- 28.15 and 150.09 +/- 30.08, DMVA = 2.34 +/- 0.75 and 2.29 +/- 0.76 respectively, and mitral regurgitation = 2 patients in both groups. The correlation between the Doppler and the 2D obtained areas was good in group A r = 0.76 SEE there were no correlation between these values in group F r = 0.33.

CONCLUSIONS

We can conclude that the mitral valvular area obtained by two-dimensional echocardiography, correlates to the Doppler mitral valvular area in patients with prior open commissurotomy proving the complementary role of the two methods.

[Prognosis in unstable angina as a function of the clinical presentation]

OBJECTIVE

To assess the prognosis of Unstable Angina according to its clinical presentation using Braunwald's Classification.

DESIGN

Retrospective study of hospital admissions from January 1982 to September 1990.

SETTING

Coronary Care Unit and a Cardiology Department of a Central Hospital.

PATIENTS

There were 132 patients, 109 men and 23 women, with a mean age of 56 +/- 9 years, all submitted to cardiac catheterization at least 90 days after hospital admission followed up during 34.2 +/- 24.2 months.

MATERIAL AND METHODS

Patients were divided in three groups according to the clinical presentation of Unstable Angina: Group A--Aggravated Chronic Angina and/or "De Novo" Angina; Group B--Angina at Rest but not in the last 48 hours, and Group C--Angina at Rest in the last 48 hours. Group A was also sub-divided, and the patients with Unstable Angina after myocardial infarction were excluded. The previous clinical profile was evaluated as well as the circumstances in which Unstable Angina occurred, need of Coronary Care Unit, angiographic findings and follow-up.

RESULTS

Within the 132 patients, 86 were in the group A, (59 with Aggravated Angina and 27 with "De Novo" Angina), 11 in group B, and 35 in group C. The group with Aggravated Angina had higher incidence of previous myocardial infarction and bypass surgery (p < 0.01 and p = 0.05), compared to group with "De Novo" Angina and B, and also three vessels disease associated to ventricular dysfunction. "Culprit Lesion" appeared more frequently as eccentric type I in group A, and as concentric in group C. Revascularization procedures were performed in 95 patients (CABG in 66 and PTCA in 29) being respectively: 21 and 6 were urgent, 19 and 18 were elective and 26 and 5 were late procedures. CABG were more frequent in group A. There were 73 major cardiac events in 44 patients (8 deaths, 12 myocardial infarction and 53 new episodes of Unstable Angina), which were more frequent in group with Aggravated Angina and group C. The chance of patients with major cardiac events was in a 78 months follow-up, about 25% for group with "De Novo" Angina, 50% for patients with Aggravated Chronic Angina, and was greater than 75% in patients with Angina at Rest and episodes in the last 48 hours (p < 0.05)--Log-rank Test. The worse prognosis was seen in patients with Aggravated Chronic Angina, when a gathering of clinic patterns of Braunwald's classification were present.

CONCLUSIONS

In summary, the group with Aggravated Angina and group C had more severe disease, required more urgent CABG and PTCA, and had also a higher incidence of cardiac events. The group with better prognosis was the group with "De Novo" Angina, which should be distinguished of the group with Aggravated Angina who was the worst prognosis.

[Ibopamine in the treatment of congestive heart failure. Multicenter follow-up study]

OBJECTIVE

To assess safety and efficacy of ibopamine, 200 mg TID, added to conventional treatment of congestive heart failure.

DESIGN

A prospective, longterm, open study over two years (1986-88). A multicenter trial.

SETTING

Outpatients of Departments of Internal Medicine of S. Francisco Xavier Hospital and Sta. Maria Hospital, and Departments of Cardiology of Sta. Cruz Hospital and Hospital Militar Principal, Lisbon.

PATIENTS AND METHODOLOGY

63 patients, 49 males from 34 to 80 years (m = 55.6 +/- 11.36) and 14 females from 41 to 80 years (m = 63 +/- 10.2), with congestive heart failure, NYHA class II in 52 patients (82.5%) and NYHA class III in 11 patients (17.5%) with a mean disease duration of 47.9 months entered into the study. Digoxin, diuretics, nitrates and antiarrhythmic drugs were allowed as concomitant therapy. Patients carried out clinical examination, ECG and laboratory tests monthly and X-Ray at the beginning and at the end of each year of the study.

RESULTS

42 patients completed one year of treatment and 20/42 continued for an additional year, 17 patients completed this second year of follow-up. From the 42 patients who completed the first year period, the NYHA class changed from II to I in 17/38 from II to III in 2/38 patients from III to II in 3/4 patients, and from III to IV in one patient. Twenty patients dropped during the first year of treatment. Six for non-compliance (less than 80% of the treatment). Two were submitted to cardiac valve surgery. Seven had cardiovascular clinical events: one ventricular tachycardia, one atrial fibrillation, one pulmonary edema, one patient had no therapeutic effect, two patients had anxiety and fatigue and one patient died suddenly. One diabetic patient had uncontrolled hyperglycemia. One patient had gastric ulcer. Two had nausea and vomiting. Dysrhythmia and nausea and vomiting were the only clinical events, considered, respectively, possibly related and related, to ibopamine. During the second year of treatment 9/11 patients were stabilized in NYHA class I and 6/9 in NYHA class II, one patient changed from class II to class I, and one patient changed from class I to class II of the NYHA. Three patients did not complete the second year of treatment; one due to abnormal creatininemia; one for probable pulmonary embolism with CHF worsening; the third died suddenly. None of these events was considered related to ibopamine. Heart rate, arterial pressure, laboratory values and cardiothoracic index did not vary over the two years of the study.

CONCLUSIONS

This has been the first study with data from patients treated with 200 mg TID of ibopamine during two years. Ibopamine has been shown to be a safe and useful drug added to conventional treatment of cardiac heart failure. Clinical events were few and well controlled after ibopamine interruption.

[Contribution of the electrocardiogram to the diagnosis of localization and extension of coronary lesions in patients with acute myocardial infarct]

With the purpose of evaluating the contribution of the ECG to the localization and extension of coronary artery lesions, 85 patients with the first acute myocardial infarction treated with thrombolysis, 79 males and 6 females (mean age 53.9 years), were studied, and the ECG changes at 3.5 and 24 hours correlated with the coronary angiographic findings before discharge. Patients were divided in two groups--Group A with anterior infarction (48 pts) and Group B with inferior infarction (37 pts).

RESULTS

A) Returning of the ST downslope to baseline in inferior and anterior leads, respectively in anterior and inferior infarction at 24 h ECG, excluded associated LAD or RCA/CX lesions with a sensitivity (S) of 93% and 87% and aspecificity (E) of 60% and 58%, with a positive predictive value (PPV) of 62% and 77% and a negative predictive value of 86% and 85% respectively. All patients with anterior infarction had LAD stenosis. B) ST upslope bigger than 5 mm in V2-V3 or its presence in D-I or aVL associated to any precordial leads, diagnosed proximal LAD lesions with S of 82% and 73% and E of 75% and 73% respectively. The left axis deviation was present in 6 of 7 patients and pointed to proximal lesion. C) In Group B patients, RCA lesion was related to ST downslope in D-I, S = 77%, E = 37.5%, PVV = 80% and NPV = 33.5%, and the proximal localization (ratio between ST downslope in V2 and ST upslope in aVF) inferior to 0.5 mm with S and NPV = 80% and E and PPV = 100%. The presence of an isoelectrical ST in D-I in association with ST upslope in V5-V6 is related to CX with S and NPV = 100%, E = 85% and PPV = 25%. In conclusion, these results suggest that a careful analysis of ECG changes in patients with first acute myocardial infarction, can provide important information regarding the infarct related artery, localization of the stenosis and the presence of associated coronary artery disease, with implications in the risk stratification before hospital discharge.

[Relationship between ventricular arrhythmia and clinical and echocardiographic parameters in hypertensive patients]

OBJECTIVE

Evaluation in arterial hypertension (HTA) patients, of the relationship between supraventricular and ventricular arrhythmias, stage of hypertension and echocardiographic parameters.

DESIGN

Retrospective study based on the files of ambulatory electrocardiography (Holter).

SETTING

Arrhythmology Outpatients Clinic from a Cardiac Department.

PATIENTS

Adult patients with arterial hypertension, males and females, who underwent ambulatory electrocardiography (Holter) and echocardiography examinations.

MATERIAL AND METHODS

Thirty patients, 15 males and females, 54 +/- 12 years old, were studied. Arterial hypertension was stratified in three stages according with the diastolic value. Symptoms, serum potassium, left ventricular hypertrophy (LVH) on the ECG, and echocardiographic parameters such as left ventricular dimensions, shortening fraction, septal wall and posterior wall thickness and left atrium dimensions were analysed. These parameters were correlated with the arrhythmic pattern concerning the number of premature supraventricular contractions and the number and complexity of premature ventricular contractions (PVC), evaluated by ambulatory electrocardiography (Holter).

RESULTS

No relation was found between the arrhythmic pattern, stage of hypertension, symptoms and LVH on the ECG. Septal wall thickness was 14 +/- 3 mm in the group of patients with PVC greater than or equal to 10/hour and 12 +/- 3 mm in the population with PVC less than 10/hour (p less than 0.04). The shortening fraction was 27 +/- 8% in the group of repetitive PVC and 34 +/- 7% in the population without (p less than 0.003). A borderline relation was found between repetitive PVC and left atrium and left ventricular diastolic dimensions.

CONCLUSIONS

In a population of arterial hypertension (HTA) who performed ambulatory electrocardiography (Holter), the prevalence of frequent or repetitive PVC was low. A positive correlation between frequent PVC and septal wall thickness and an inverse relation between repetitive PVC and LV shortening fraction, was found. These conclusions are according with the literature, relating the ectopic activity with LVH or deterioration of LV function. No relation was found between arrhythmias and stage of hypertension.

[Non-invasive evaluation of a population with WPW syndrome]

OBJECTIVE

Evaluation of a WPW Syndrome population by non invasive methods; identification of the sudden death risk; results of treatment and patient selection for Electrophysiologic Studies (EPS).

DESIGN

Retrospective study.

SETTING

Arrhythmology Outpatients Clinic from a Cardiac Department.

PATIENTS

Successive patients older than 12 years with a WPW pattern on the ECG and history of paroxysmal tachycardia followed-up for a period of 46 +/- 29 months.

MATERIAL AND METHODS

The clinical, ECG, Holter, stress test and echocardiographic data from 32 patients, were analysed. A study evaluating clinical follow up and the results of treatment was done.

RESULTS

The group of patients was very symptomatic. The main complaint was a feeling of tachycardia (84.4%). Orthodromic tachycardia was documented in 7 cases and atrial fibrillation with rapid ventricular rate in five. Intermittent delta wave pattern was found in 21 patients, with 11 cases identified by Holter and 4 by stress test. A predominant left accessory pathway was found (47%), but the anteroseptal location was frequent too (25%). The echocardiogram was not useful in any case. Eighty per cent of the patients became asymptomatic with medical treatment. Beta blockers and amiodarone (the last chance) were the most useful drugs. No mortality was found in the study group. EPS was considered for the 5 patients with paroxysmal atrial fibrillation and the 7 cases resistant to medical treatment.

CONCLUSIONS

The difficulty to define the risk of a population with WPW Syndrome by non invasive methods was demonstrated. Eighteen one cases were included in a low risk group, due to the intermittent WPW pattern in the ECG. A high risk group was considered for the 5 patients with atrial fibrillation with fast ventricular rate. The risk was not established in 9 cases. Most of the patients became asymptomatic by medical treatment.

[Echo-Doppler in patients undergoing mitral commissurotomy. Comparison of open and closed commissurotomy]

OBJECTIVE

1. To evaluate with Echo-Doppler the medium/long term results of mitral commissurotomy. 2. To compare the results of open mitral commissurotomy to those of closed commissurotomy.

PATIENTS AND METHODS

The Echo 2D-Doppler study has been performed in 117 patients (104 females and 13 males), randomly selected among patients previously submitted to open (62 d.) or closed (55 d.) mitral commissurotomy, with greater than or equal to 12 months follow-up. Pulsed and continuous Doppler recordings were obtained in all 117 patients, and the following parameters were evaluated: Maximum Mitral Gradient (MG); mitral valvular area calculated by half-pressure time (MVA); presence of mitral regurgitation greater than or equal to grade 2 (MR); evaluation of systolic Pulmonary Artery pressure (PAP) by the gradient RV/RA + 14mmHg, in the patients with tricuspid insufficiency; acceleration time (ACT), ejection time (EJT) and the relation ACT/EJT in pulmonary artery. To compare the results of open commissurotomy, to those of closed commissurotomy, and in order to minimize the pre-operative differences between the patients submitted to each of these interventions, only the patients in the same NYHA functional class before surgery (class III), and in sinus rhythm have been selected. In this way two groups were compared: group A-24 patients with open commissurotomy and group F-37 patients with closed commissurotomy.

RESULTS

in the total of patients the results were: MG-9.8 +/- 4.2 mmHg; MVA-2.3 +/- 0.95 cm2; MR 16 pts. (13.7%); PAP obtained in 30 pts. (25.6%) -27.47 +/- 1.18 mmHg; the ACT, the EJT and the relation ACT/EJT in PA were respectively 115.63 +/- 34 ms, 309.9 +/- 38.5 ms, 0.37 +/- 0.1. The Doppler parameters obtained respectively in group A and in group F were: MG 8.96 +/- 4.5 mmHg and 10.38 +/- 3.82 mmHg (ns); MVA 2.62 +/- 1.01 cm2 and 2.08 +/- 0.84 cm2 (ns); MR 8.3% and 15.6% (ns) (Fig.3); the PAP have been calculated on 5(20.8%) patients in group A and on 10(27%) patients in group F and their respective values were 30.78 +/- 0.48 mmHg and 28.26 +/- 1.11 mmHg (ns); ACT 109.09 +/- 41.55 ms and 116.67 +/- 33.22 ms (ns); EJT 297.27 +/- 72.94 ms and 308.7 +/- 41.58 ms; ACT/EJT 0.35 +/- 0.12 and 0.38 +/- 0.10 (ns).

CONCLUSION

Both open and closed commissurotomy revealed to be good therapeutic alternatives to mitral stenosis with identical long term results as evaluated by Echo-Doppler. The results of percutaneous mitral valvuloplasty should be compared with these in the future.

[Diagnostic value of the submaximal treadmill exercise test in the subacute phase of myocardial infarct]

OBJECTIVES

To assess the diagnostic value of treadmill submaximal exercise testing (TSET), early after myocardial infarction (MI) under medical treatment, evaluating the ST changes predominantly.

MATERIALS AND METHODS

65 patients, 62 males and 3 females, mean age 52 years with demonstrated MI under clinical, electrocardiographic and enzymatic criteria were evaluated with TSET before hospital discharge. Thrombolytic therapy in acute phase of MI was done in 45 of the patients. All patients underwent angiographic studies with left ventriculography and selective coronariography.

RESULTS

Of all TSET variables considered (Treadmill time, ST segment, presence of chest pain, systolic pressure, double product and presence of ventricular arrythmias) the single most important predictor for high-risk groups like left main disease and three vessels disease, was ST changes alone or associated with exercise precordial pain, with a sensitivity of 100% to left main and 83% to three vessels disease. In the thrombolytic group we did not find any differences related with reperfusion.

IN CONCLUSION

TSET is a useful, noninvasive, and safe method for risk stratification after MI mainly when ST segment changes are considered alone or with stress precordial pain, predicting high risk groups, namely left main or three vessels disease patients.

[From cardiac catheterization to the study of left ventricular function. Importance of relaxation and diastole in ischemic cardiopathy]

Some of the most recent developments on left ventricular function derived from Brutsaert's work on triple control of contraction and relaxation, and on the new division of the different phases of the cardiac cycle, are reviewed. This allows a re-assessment of the different hemodynamic parameters obtained from cardiac catheterization, which were then applied to relaxation and diastole and to coronary artery disease.

[Pulmonary valvotomy in adults. The double balloon technic--apropos of 2 cases]

Percutaneous double balloon valvotomy was performed in two adult patients with severe non dysplasic pulmonary valvular stenosis. The balloons were introduced through two 14F sheaths placed in the right and left femural veins, the intervention was well tolerated and succeeded with a marked decrease in right ventricular pressure and in pulmonary transvalvular gradient (113 and 147 mmHg to 10 and 12 mmHg respectively). The patients were discharged within 24 hours, without the need of Intensive Care admission. Indications for the procedure and technical aspects are presented, as well as the potential advantages of two balloons over one balloon and surgical valvotomy.

[Percutaneous mitral valvotomy]

We report the first percutaneous mitral valvotomy performed in Portugal in October 19th 1987. The valvotomy was attempted successfully in a 34 year old man, with calcific mitral stenosis, in NYHA class III, with functional mitral valve area less then 1 cm2. The intervention was performed using the transseptal technique with two balloons (20 and 18 mm in diameter), placed in the mitral valve annulus through two long transseptal sheaths (14F). The procedure resulted in a marked decrease in the diastolic transmitral gradient, and an increase in mitral valve area superior to 100%. No immediate or late complications were observed, namely mitral regurgitation or left to right shunt through the atrial septum. One year later the patient is in NYHA class I, with a mitral valve area of 1.7 cm2.