Evaluation of Lower Limb Arteriovenous Diameters in Indoor Soccer Athletes: Arterial Doppler Ultrasound Study

The purpose of this study was to analyze the arterial and venous diameters of lower limbs in indoor soccer athletes and non-athletes using Doppler ultrasound to identify the differences in the variation of arterial and venous diameters between groups. Additionally, we intended to verify the differences of arterial and venous diameters between the skilled member (right member) and the not skilled member in each group. 74 male volunteers, aged between 19 and 30 years old, were divided in a group of athletes (n = 37, 24 ± 2.7 years, soccer players from national championship), and a group of non-athletes (n = 37, 26 ± 2.83 years). Vascular lower limb was assessed using Doppler ultrasound (Philips HD7 echograph with linear transducer 7–12 MHz). The athletes showed higher diameters of right common femoral artery (p = 0.009; moderate), left common femoral artery (p = 0.005; moderate), right deep femoral artery (p = 0.013; moderate), right popliteal artery (p = 0.003; moderate), and left popliteal artery (p = 0.017; small) than non-athletes. Veins’ diameters were also higher in athletes, specifically the right deep femoral vein (p ≤ 0.001; large), left deep femoral vein (p ≤ 0.001; large), right popliteal vein (p ≤ 0.001; large), and left popliteal vein (p ≤ 0.001; large). Differences were found between the skilled and non-skilled leg in athletes in the popliteal vein (7.68 ± 1.44 mm vs. 7.22 ± 1.09 mm, respectively, p < 0.003). It seems that futsal athletes have superior mean diameters of lower limbs arteries and veins of the deep venous system to non-athletes. Moreover, the veins presented greater dilation, namely of the leg of the skilled lower limb.

Variability of Lower Limb Artery Systolic-Diastolic Velocities in Futsal Athletes and Non-Athletes: Evaluation by Arterial Doppler Ultrasound

Background: Sports athletes, namely high-intensity practitioners, suffer from vascular remodeling overtime. The purpose of this study was to analyze the systolic and diastolic velocities’ variation between non-athletes and futsal athletes by means of arterial lower limb doppler ultrasound. Additionally, we intended to verify if the velocity variations occur primarily at the systolic or the diastolic level and in which arteries. Methods: Seventy-six young males (mean ± SD: 24.9 ± 2.8 years old) volunteered to participate in this cross-sectional study and were divided into two groups: a futsal athletes group (n = 38; 24 ± 2.78 years) in the central region of Portugal playing on the 2nd national league with the same level of practice (16 ± 2.4 years of practice) and a non-athletes group (n = 38: 26 ± 1.8 years) who did not practice sports regularly and were not federated in any sport. All the subjects agreed to participate in the study with the aim of assessing the arterial lower limb through doppler ultrasound (Philips HD7 echograph with linear transducer 7–12 MHz). Results: Differences between groups (p ≤ 0.05) in the systolic velocity of the left deep femoral artery (p = 0.022; d = 0.546, small) and in the right superficial femoral artery (p = 0.028; d = −0.515, small) were found. We also found differences in the diastolic velocity: in the left common femoral artery (p = 0.002; d = −0.748, moderate), in the right deep femoral artery (p = 0.028; d = −0.521, small), in the right superficial femoral artery (p = 0.026; d = −0.522, small), in the right popliteal artery (p = 0.002; d = −0.763, moderate), and in the left popliteal artery (p = 0.007; d = −0.655, moderate). Moreover, the athletes’ group presented the highest mean values, with the exception of the systolic velocity of the left deep femoral artery. In intragroup analysis of variance referring to systolic and diastolic velocities in arterial levels in the right and left arteries, differences were found in all analyses (p ≤ 0.05). Conclusions: We conclude that futsal athletes of our sample go through a process of changes such as increased blood flow velocity in systolic and diastolic cardiac phase in all studied lower limb arteries, showing that the remodeling occurs regardless of vessel radius. Our results reinforce the existence of vascular remodeling that may vary with the sport and its intensity.

A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism: The OPTALYSE PE Trial

OBJECTIVES

The aim of this study was to determine the lowest optimal tissue plasminogen activator (tPA) dose and delivery duration using ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk (submassive) pulmonary embolism.

BACKGROUND

Previous trials of USCDT used tPA over 12 to 24 h at doses of 20 to 24 mg for acute pulmonary embolism.

METHODS

Hemodynamically stable adults with acute intermediate-risk pulmonary embolism documented by computed tomographic angiography were randomized into this prospective multicenter, parallel-group trial. Patients received treatment with 1 of 4 USCDT regimens. The tPA dose ranged from 4 to 12 mg per lung and infusion duration from 2 to 6 h. The primary efficacy endpoint was reduction in right ventricular-to-left ventricular diameter ratio by computed tomographic angiography. A major secondary endpoint was embolic burden by refined modified Miller score, measured on computed tomographic angiography 48 h after initiation of USCDT.

RESULTS

One hundred one patients were randomized, and improvements in right ventricular-to-left ventricular diameter ratio were as follows: arm 1 (4 mg/lung/2 h), 0.40 (24%; p = 0.0001); arm 2 (4 mg/lung/4 h), 0.35 (22.6%; p = 0.0001); arm 3 (6 mg/lung/6 h), 0.42 (26.3%; p = 0.0001); and arm 4 (12 mg/lung/6 h), 0.48 (25.5%; p = 0.0001). Improvement in refined modified Miller score was also seen in all groups. Four patients experienced major bleeding (4%). Of 2 intracranial hemorrhage events, 1 was attributed to tPA delivered by USCDT.

CONCLUSIONS

Treatment with USCDT using a shorter delivery duration and lower-dose tPA was associated with improved right ventricular function and reduced clot burden compared with baseline. The major bleeding rate was low, but 1 intracranial hemorrhage event due to tPA delivered by USCDT did occur.

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis

BACKGROUND

The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.

METHODS

We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up.

RESULTS

Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups.

CONCLUSIONS

Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335 .).

Pretransplant biopsy in expanded criteria donors: do we really need it?

INTRODUCTION

Renal transplantation is the best treatment for end-stage renal disease, including when using expanded criteria donors (ECD) kidneys. However, these suboptimal kidneys should be evaluated rigorously to meet their usefulness. Opinions differ about the best way to evaluate them.

MATERIALS AND METHODS

We retrospectively reviewed kidneys from ECD harvested by a single academic institution between January 2008 and September 2013. Needle biopsies were performed at the time of the harvest when considered relevant by the transplant team. Two pathologists where responsible for their analysis; the Remuzzi classification has been used in all cases.

RESULTS

We evaluated 560 ECD kidneys. Biopsies were made in 197 (35.2%) organs, 20 of which were considered not usable and 36 good only for double transplantation. Sixty-three kidneys (11.3%) were discarded by the transplant team based on the biopsy result and clinical criteria. Donors who underwent a biopsy were older (P < .001) and had a worse glomerular filtration rate (GFR; P = .001). Comparing donors approved and rejected by the biopsy, the rejected donors were heavier (P = .003) and had a lower GFR (P = .002). Cold ischemia time was longer for the biopsy group (P < .001). Regarding graft function, the biopsy overall score correlated with the transplant outcome in the short and long term. Separately, glomeruli and interstitium scores were correlated with recipient's GFR in the earlier periods (3 months; P = .025 and .037), and the arteries and tubules correlated with GFR in the longer term (at 3 years P = .004 and .010).

CONCLUSION

The decision on the usability of ECD grafts is complex. At our center, we chose a mixed approach based on donor risk. Low-risk ECD do not require biopsy. In more complex situations, especially older donors or those with a lower GFR, prompted a pretransplant biopsy. The biopsy results proved to be useful as they relate to subsequent transplant outcomes, thereby allowing us to exclude grafts whose function would most probably be less than optimal.

Primary squamous cell carcinoma of the most distal rectum: a dilemma in origin and management

Squamous cell carcinoma (SCC) of the rectum is a rare malignant entity that has been classically managed with a surgery-based approach, which included abdominoperineal resection for distal lesions. Recently there have been reports on the favourable outcomes achieved with the non-surgical management of these patients. We report a case of a 52-year-old woman who was diagnosed with a stage IIIa SCC located on the distal rectum. The patient was managed conservatively with a chemoradiation regime with mitomycin and 5-fluorouracil. Complete remission was achieved and she is currently alive, asymptomatic and disease-free after 30 months. This case adds to the existing evidence that supports the role of chemoradiation as a first-line curative treatment for the rare rectal SCC.

[Loeffler's endocarditis--a case report]

Loeffler's endocarditis is an acute form of primary restrictive cardiomyopathy. We report the case of a young woman with pleuritic chest pain associated with fever and hypereosinophilia. She was hospitalized with suspected acute myopericarditis and was treated with aspirin, leading to clinical improvement. Ten days after discharge, she was rehospitalized due to recurrence of chest pain. The echocardiogram showed what appeared to be a mass filling the apex of the right ventricle (RV). She was referred for magnetic resonance imaging, which revealed marked myocardial thickening in the apex of the RV. The patient underwent an endomyocardial biopsy, resulting in a diagnosis of eosinophilic endocarditis. After treatment with prednisolone, all symptoms and the eosinophilia disappeared, and there was complete remission of the RV abnormalities. After three years of follow-up, the patient remains asymptomatic. This case shows that, even without an etiologic diagnosis of eosinophilia, the prognosis for Loeffler's endocarditis can be favorable if treatment is initiated early.

Female gender: an independent factor in ST-elevation myocardial infarction

INTRODUCTION

Cardiovascular disease is the leading cause of death in women. In ST-elevation myocardial infarction (STEMI) in particular, the question has been raised whether specific characteristics of women confer a worse prognosis.

OBJECTIVE

To evaluate the differences in STEMI patients between the genders in cardiovascular risk profile, clinical presentation, therapeutic approach and in-hospital and 6-month mortality rates.

METHODS

We analyzed 1578 patients admitted consecutively with STEMI during a 7-year period (from January 13, 2002 to December 31, 2008). The patients were divided into two groups according to gender, and compared in terms of baseline clinical and demographic characteristics, pre-hospital and in-hospital delay, clinical presentation on admission, reperfusion therapy, severity of coronary disease and in-hospital and 6-month mortality.

RESULTS

Of the 1578 patients, 26% were female. Women were older (by 8 years), and had a higher cardiovascular risk profile. On admission, their clinical presentation was more severe, with a higher frequency of anterior myocardial infarction and acute heart failure symptoms. Women had longer ischemic times and lower rates of reperfusion therapy. Mortality in women was significantly higher than in men, both in-hospital (17.5 vs. 5.3%) and at 6 months (23.5% vs. 8.2%). After adjustment in multivariate analysis, mortality in women remained higher.

CONCLUSIONS

The adverse demographic and clinical profile could partially explain the worse prognosis of STEMI in women. This, together with longer pre-hospital delays, led to underuse of reperfusion therapy. Even so, female gender by itself had a negative and independent influence on mortality in STEMI patients.

A case of rare longevity of tetralogy Fallot

Tetralogy of Fallot is one of the most common forms of cyanotic congenital heart disease. In the absence of surgical correction it has high early mortality, with most patients dying in childhood. Survival beyond the seventh decade of life is extremely rare. The authors present the case of a patient with uncorrected tetralogy of Fallot who survived to the age of eighty. The longevity of this patient is certainly linked to the association between a large ventricular septal defect and "balanced" pulmonary stenosis: sufficiently mild not to cause severe hypoxia, but significant enough to protect the pulmonary vasculature.

Apical ballooning syndrome--a review of five cases

INTRODUCTION

Takotsubo syndrome (apical ballooning syndrome) was described for the first time in Japan, at the beginning of the 1990s. It is characterized by the acute onset of extensive but transient akinesia of the apical and mid portions of the left ventricle, in the absence of significant coronary disease.

OBJECTIVE

We describe five patients who were admitted to our hospital with this new syndrome between June 2004 and December 2005. These patients represented 0.8% of a total of 613 patients admitted for acute myocardial infarction in that period.

RESULTS

All the patients were female, with a mean age of 60.2+/-10.3 years. Chest pain was the most frequent clinical presentation (n=5). A possible triggering factor, intense emotional stress, was identified in two patients. At admission, the electrocardiogram showed ST elevation in two patients and Q waves in the precordial leads in one. All cases had negative T waves in the precordial leads at some point. All patients had increased troponin levels but only two had elevated cardiac enzymes. The echocardiogram revealed extensive akinesia of the apical and mid portions of the left ventricle, and a thrombus was observed in one patient. Coronary angiography showed no significant lesions. Currently, all five patients are virtually asymptomatic, with regression of left ventricular wall-motion abnormalities on echocardiography.

CONCLUSION

This is the first series of apical ballooning syndrome described in Portugal. Although rare, it should be considered in the differential diagnosis of acute myocardial infarction. Despite its transient nature, in the acute phase it can be a serious condition. More research is needed to better characterize this new entity.

[Angiography of the coronary venous system. Use in clinical electrophysiology]

PURPOSE

To study the angiographic anatomy of human coronary veins and the possibility of epicardial venous mapping through microelectrode catheters.

METHODS

We evaluated 30 patients with sustained ventricular tachycardia using a catheter which provided occlusion of the coronary sinus ostium during venous angiography. They were 25 males, 5 females, ages ranging from 24 to 76 years (mean = 52.7). The veins were studied according to their number, caliber and distribution in the anterior and posterior wall of the left ventricle.

RESULTS

Coronary sinus was catheterized in all patients. No discomfort or complication were observed. The number of veins from posterior wall of the left ventricle was 3.1 and anterior wall, 1.9, p < 0.05. The caliber of the coronary veins were: anterior interventricular vein (distal segment = 1.19 +/- 0.22 mm, middle segment = 1.65 +/- 0.35 mm), posterior interventricular vein (distal segment = 1.83 +/- 0.47 mm, middle segment = 2.00 +/- 0.52 mm), left posterior vein (distal segment = 1.45 +/- 0.25 mm, middle segment = 2.49 +/- 0.92 mm); p < 0.05.

CONCLUSION

The balloon occlusion technique for coronary venous angiography is feasible and safe. The number and the caliber (distal and middle) of the veins from the posterior wall of the left ventricle were significantly greater than those from the anterior wall. Anatomic conditions for venous epicardial mapping are more adequate in the posterior wall of the left ventricle.

Treatment of hypercholesterolemia in patients undergoing multiple coronary angioplasties

BACKGROUND

Hypercholesterolemia is a known risk factor for coronary artery disease (CAD). Multiple studies have shown that its treatment will reduce the rate of progression of coronary atherosclerosis and lead to regression of the atherosclerotic process. Recent studies have also shown impact on mortality. Angioplasty (PTCA) is a well established revascularization procedure for many of these patients. In this study we investigated whether or not therapy for hypercholesterolemia in patients undergoing elective PTCA had been instituted and, if so, whether desirable cholesterol levels had been achieved.

METHODS

We reviewed the charts of 129 patients (pts) who were consecutively admitted for elective PTCA between September 1993 and August 1994. All pts. had at least one PTCA in the past and all of them had the diagnosis of hypercholesterolemia. The list was made using a computer search of all pts. meeting the previous two diagnoses. Pts on whom PTCA was performed in the setting of acute ischemic events were excluded as well as pts with no known history of hypercholesterolemia.

RESULTS

In 13 out of 129 pts., it was not possible to find cholesterol levels. The 116 pts in whom cholesterol levels were available were divided in two groups. Group I (54 pts.-46.5%) included pts. not being treated with any lipid lowering agent and group II (62 pts.-53.5%) included pts being treated with at least one of those drugs. Both groups were further subdivided into "A" and "B", depending on whether the PTCA was being performed because of a "new" lesion or because of "restenosis", respectively. Group IA had a total of 31 pts, IB 23 pts, IIA 29 pts and IIB, 33 pts. Group I pts had an average of 3.40 PTCA's and a mean cholesterol level of 227 mg/dl. Group II pts had an average number of PTCA's of 3.34 and a mean cholesterol level of 228 mg/dl. Group IA had an average number of PTCA's of 3.65 and a mean cholesterol level of 221 mg/dl; for group IIA these values were, respectively, 3.17 and 221 mg/dl. Group IB had an average number of procedures of 3.09 while for group IIB this number was 3.49; the mean cholesterol levels were, respectively, 235 mg/dl and 234 mg/dl. None of these differences is statistically significant. Group I had 14 pts (26%) with cholesterol levels below 200 mg/dl while group II had 16 pts. with cholesterol levels below 200 mg/dl (26%). In group I, 8 pts (14%) had lipid profiles documented. Only 1 pt. had an LDL level below 100 mg/dl and only 3 pts had an LDL level below 130 mg mg/dl. In group II, 15 pts (24%) had a lipid profile documented. Of these, no pt. had an LDL level below 100 mg/dl and only 4 pts had an LDL level below 130 mg/dl.

CONCLUSIONS

A significant percentage of pts. undergoing multiple PTCA's are not being treated or monitored adequately for hypercholesterolemia despite aggressive invasive management.