Atrial matrix remodeling in atrial fibrillation patients with aortic stenosis

BACKGROUND

This study aimed to evaluate atrium extracellular matrix remodeling in atrial fibrillation (AF) patients with severe aortic stenosis, through histological fibrosis quantification and extracellular matrix gene expression analysis, as well as serum quantification of selected protein targets.

METHODS

A posthoc analysis of a prospective study was performed in a cohort of aortic stenosis patients. Between 2014 and 2019, 56 patients with severe aortic stenosis submitted to aortic valve replacement surgery in a tertiary hospital were selected.

RESULTS

Fibrosis was significantly increased in the AF group when compared to sinus rhythm (SR) patients (p = 0.024). Moreover, cardiomyocyte area was significantly higher in AF patients versus SR patients (p = 0.008). Conversely, collagen III gene expression was increased in AF patients (p = 0.038). TIMP1 was less expressed in the atria of AF patients. MMP16/TIMP4 ratio was significantly decreased in AF patients (p = 0.006). TIMP1 (p = 0.004) and TIMP2 (p = 0.012) were significantly increased in the serum of AF patients. Aortic valve maximum (p = 0.0159) and mean (p = 0.031) gradients demonstrated a negative association with serum TIMP1.

CONCLUSIONS

Atrial fibrillation patients with severe aortic stenosis present increased atrial fibrosis and collagen type III synthesis, with extracellular matrix remodelling demonstrated by a decrease in the MMP16/TIMP4 ratio, along with an increased serum TIMP1 and TIMP2 proteins.

Soft tissue sarcomas in the elbow region and influence of their anatomical features in their treatment. Experience in the Unit of Musculoskeletal Tumours

BACKGROUND AND AIM

Soft tissue sarcomas are exceptionally located in the elbow region. The aim of this work was to study the soft tissue sarcomas of the elbow region, their epidemiological and histopathological characteristics, anatomical features, the treatment performed, and the results obtained, in a unit of musculoskeletal tumours.

METHODS

Retrospective review of ten patients with a mean follow-up of 65.0 ± 11.9 (range 21-132) months with soft tissue sarcomas located in the elbow region operated in our centre between 2008 and 2016.

RESULTS

Mean age was 60.8 ± 6.7 years. Undifferentiated pleomorphic sarcoma was the most frequent histological diagnosis. Limb preservation surgery was performed in 90% of patients. Three patients were previously operated without following surgical oncology guidelines in another hospital, and this was statistically related to the need for more than one surgery to control the disease. R1 margin was obtained in 5 patients and R0 in another 5. Adjuvant radiotherapy was used in 7 cases. In 4 patients, subsequent surgery was performed for local or systemic control of the disease. Local recurrence occurred in 3 cases and in 5 there was distant disease.

CONCLUSION

The elbow region presents difficulty in achieving wide margins due to the proximity of neurovascular structures, adjuvant and / or neoadjuvant therapies could play an important role in performing limb preservation surgery. It would be advisable to refer these tumours to specialized units with multidisciplinary teams.

Functional evaluation of patients with anterior cruciate ligament injury. A transversal analytical study

OBJECTIVE

To evaluate, by means of biomechanical analysis, functional alterations of gait and balance of patients with anterior cruciate ligament (ACL) injury.

MATERIAL AND METHODS

Transversal analytical study on 64 people, 27 health subjects and 37 patients with ACL injury. Biomechanical analysis of gait in all individuals was performed by means of four tests: 1) kinematic test, to characterize gait pattern; 2) kinetic test, to characterize forces against the floor, duration of treads, symmetry of both legs, and the reproducibility of the gait; 3) pivot-shift test, to analyze the rotational stability of the knee on the sagittal axis; and 4) equilibrium test.

RESULTS

alterations in kinematic and kinetic analysis were found in both the injured knee and the healthy knee compared to the control group. In the pivot-shift gait test there is a tendency to increase the forces on the three axes, both in the support leg and in the exit leg in patients with ACL injury, in comparison with healthy subjects.

CONCLUSION

ACL injury-induced changes in gait pattern, changes in forces against the floor, duration of treads, symmetry of both legs, and the reproducibility of gait and changes in rotational stability of the knee on the sagittal axis.

Calcific tendinopathy of the shoulder with intraosseous extension: experience with arthroscopic treatment and review of the literature

BACKGROUND AND AIM

Calcific tendinitis of the rotator cuff is a common cause of shoulder pain. The aim of the present study was to show a rare presentation of calcific tendinopathy of the shoulder, the intraosseous extension, which can be mistaken for a bone tumour or an infectious disease.

MATERIAL AND METHODS

Two clinical cases of calcific tendinopathy of the shoulder with intraosseous extension and a review of the literature are presented.

RESULTS

Cortical erosion, osteolytic lesion in the greater tuberosity and perilesional oedema were observed in both cases. Good results were achieved with shoulder arthroscopy including lesion debridement and reinsertion of the tendon in the greater tuberosity with an anchor.

CONCLUSIONS

In the presence of an osteolytic lesion with perilesional oedema in the greater tuberosity, the intraosseous expansion of a calcifying tendinopathy should be included in the differential diagnosis. In our cases the arthroscopic treatment was successful.

Use of topical tranexamic acid in primary total hip arthroplasty. Efficiency and safety. Our experience

BACKGROUND AND AIM

Intravenous tranexamic acid has been shown to reduce bleeding and the need for transfusions in total hip arthroplasty, although it has a theoretical risk of producing thromboembolic phenomena. Recently some papers have been published using the topical application of tranexamic acid, but the ideal administration protocol has not yet been clearly defined. The aim of this paper was to demonstrate that our protocol of topical tranexamic acid is effective and safe.

MATERIALS AND METHODS

Prospective data collection from a case series of 80 primary hip arthroplasties, in which the following topical tranexamic acid protocol is used: 1.5 grams diluted to a total volume of 60ml were administered, applying 20ml in the acetabular bed, 20ml in the femoral canal and 20ml through the Redon drain, keeping it closed for 20minutes.

RESULTS

Eighty patients were operated. Preoperative haemoglobin 14.26g / dL; preoperative haematocrit 42.39%. An average loss of 2.74g / dL of haemoglobin and 8% of haematocrit was obtained. Eleven percent of the patients required transfusion, of whom 67% had known previous anaemia; only 3 patients without prior anaemia required transfusion (4%). There were no thromboembolic complications in our series.

CONCLUSIONS

The use of topical tranexamic acid was safe and effective in primary total hip arthroplasty, reducing the need for blood transfusion compared to that described in the literature in untreated patients.

Superior labral anterior to posterior (SLAP) injury in the workplace

BACKGROUND AND OBJECTIVE

Superior labral anterior to posterior (SLAP) injuries are widely recognised as a cause of pain and dysfunction in the shoulders of active patients. The aims of the present study were to analyze SLAP injuries in the workplace, and to evaluate the reliability of physical examination and imaging techniques for the diagnosis of work-related SLAP injuries.

MATERIAL AND METHODS

Retrospective chart review of 58 SLAP injuries treated in our occupational health centre from 2005 to 2015 in 815 patients undergoing shoulder arthroscopy. Data were collected on mechanism of injury, clinical proceedings, complementary tests (contrasting the initial magnetic resonance imaging report with that of a radiologist specializing in musculoskeletal pathology), arthroscopy findings and treatments performed.

RESULTS

The most common mechanism of injury was acute injury while handling weight, in the majority of cases, above the head. SLAP injury was suspected in 41% of cases through anamnesis and physical exam, in 29% through the initial magnetic resonance imaging report, and in 52% through the specialised radiologist's report. In 78%, associated injuries were present, the most common being rotator cuff injuries.

CONCLUSIONS

SLAP injuries in the workplace are rare and are often a diagnostic finding during surgical intervention performed for a different associated injury. Arthro-magnetic resonance imaging and magnetic resonance imaging have lower reliability than physical exams in the diagnosis of work-related SLAP injuries. A radiologist specializing in musculoskeletal pathology could probably improve the reliability of imaging test interpretation in work-related SLAP injuries.

Abstract P5-22-19: Nipple sparing mastectomy in unselect patients: Experience of an academic center in the south of Brazil

INTRODUCTION: Nipple sparing mastectomy (NSM) consists in the complete excision of the breast gland, mantaining the subcutaneous tissue, skin and nipple-areola complex (NAC). Recently, the NSM was developed as a therapeutic option not just for the patients that need risk-reducing surgery, but also for patients that have tumors not involving the NAC.

OBJECTIVES: Evaluate the overall survival, disease-free survival and local recurrence of the patients that underwent NSM. The only exclusion criteria for NSM was lesion at the NAC.

MATERIAL AND METHODS: Retrospective study that evaluate the number of cases of NSM performed between 2003 and 2015 in a private sector in the south of Brazil.

RESULTS: A total of 224 patients underwent NSM during the period of 2003-2015. The mean age was 47 years. From the total, 43 patients underwent risk-reducing NSM and 181 therapeutic NSM (64 unilateral and 117 bilateral). In those cases of bilateral procedures all of them underwent risk-reducing surgery on the contralateral breast (there were no bilateral cancers). Of this 181 cases, 108 (59%) have familiar history of breast cancer, considering first, second and third-degree relatives. Twenty six patients (14%) have history of previous breast cancer diagnosed. In this group of 181 patients with therapeutic NSM, 29 (16%) developed any unfavorable outcomes, 13 (7%) local recurrence, 4 (2%) ipsilateral node recurrence, 3 (1,6%) contralateral recurrence and 9 (5%) distant metastasis. None of the local recurrences occurred at the NAC, neither the cited unfavorable outcomes occurred in the risk-reducing setting. In a median follow-up of 47,7 months, the overall survival was 95% (8 deaths related to breast cancer) and the disease-free survival was 83,7%.

CONCLUSIONS: The overall survival rates of 95% at 47 months of follow-up is similar to the literature rates, that range from 93 to 97% in 5 years, depending on study's inclusion criterias. In our study, 14% of patients had previous breast cancer and 59% of patients treated for breast cancer by NSM had positive familiar history of breast cancer. This results in an unselected group of patients confirms the safety of this therapeutic method as an option for breast cancer patients.

Citation Format: Frasson A, Zerwes F, Souza A, Rossato N, Miranda I, Trindade V, Vollbrecht B, Santos M, Viegas J. Nipple sparing mastectomy in unselect patients: Experience of an academic center in the south of Brazil [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-19.

Correction to: Satellite Images Combined with Field Data Reveal Negative Changes in the Distribution of Babassu Palms after Clearing off Amazonian Forests

The original article has been corrected.

Satellite Images Combined with Field Data Reveal Negative Changes in the Distribution of Babassu Palms after Clearing off Amazonian Forests

When the Amazonian rain forest is cut to create pasture, some of the original vegetal species survive clearing, even expressing their ability to invade agro-systems. It is true of the babassu palm, which can be considered, paradoxically, a natural resource by the "Interstate Movement of Babassu Fruit Breaker Women" or as native weed by land owners-farmers. To manage potential conflict of land uses, we study here the current density of this palm tree in different habitats, based on a combination of field data and remote sensing data. Firstly, we checked that the field survey methodology (i.e., counting free-trunk palm trees over 20 cm in circumference) provides density values compatible with those stemming from satellite images interpretation. We can see then that, a PA-Benfica Brazilian territory revealed an average density of the babassu lower in pastures (2.86 ind/ha) than in the dense forest (4.72 ind/ha) from which they originate and than in fallow land (4.31 ind/ha). We analyze in detail density data repartition in three habitats and we discuss results from the literature on the density of this palm tree versus its resilience at different developmental stages after forest clearing, depending on anthropogenic-or not-factors, including solar radiation, fire, weeding, clear cutting, burying fruit, and competition with forage grass. All these results can be exploited for the design of future management plans for the babassu palm and we think that the linked methodology and interdisciplinary approach can be extended to others palms and trees species in similar problematic issues.

The H.U.G.E. Formula (Hematocrit, Urea, Sex) for Screening Chronic Kidney Disease (CKD) in an Age-Stratified General Population

OBJECTIVES

AIM

To evaluate the screening power of the HUGE formula for the detection of chronic kidney disease (CKD) in a Spanish population sample obtained from the HERMEX study, a survey of cardiovascular risk factors carried out in the region of Extremadura, stratified by age.

DESIGN AND METHODS

This was an observational, cross-sectional, population-based study. The final sample included 2,813 subjects selected from Health Care System records. Anthropometric data and cardiovascular risk factors were recorded. Hematocrit, urea, creatinine and microalbuminuria were analyzed, after which the HUGE formula was applied. Renal function, assessed as eGFR based on serum creatinine, was estimated following the MDRD-4 formula.

RESULTS

Using the HUGE formula, the estimated prevalence of CKD was 2.2% (men 2.2%, women 2.1%). The prevalence of CKD increased with age (5.0% in persons aged 60- 70 years and 9.6% in individuals over 70 years of age, p < 0.001) whereas with the MDRD formula the prevalence values were 9.8% and 15.5% respectively. The HUGE formula was seen to be highly specific (0.99). CKD was more common in persons >70 years, obese subjects, hypertensive patients, dyslipidemic subjects and those with microalbuminuria. Multivariate analysis revealed an independent negative association of CKD as the dependent variable with SBP, serum triglyceride levels and microalbuminuria.

CONCLUSIONS

The HUGE formula allows the prediction of CKD in the general population to be honed without relying on serum creatinine levels. This method was found to have a higher specificity than the MDRD-4 formula. Moreover, it could reduce the excessively extensive diagnostic suspicion of CKD in women.

Visceral leishmaniasis in captive wild canids in Brazil

Visceral leishmaniasis (VL) is endemic in Belo Horizonte (State of Minas Gerais, Brazil). Leishmania sp. can naturally infect several species of mammals, and the domestic dog is the most important reservoir of the disease in South America. This report describes five cases of visceral leishmaniasis in Brazilian canids. Among 15 animals kept in captivity in a zoo in Belo Horizonte (State of Minas Gerais, Brazil), two animals, a bush dog (Spheotos venaticos) and a hoary zorro (Lycalopex vetulus) were serologically positive and developed clinical signs of VL, whereas three other canids, including a crab-eating fox (Cerdocyon thous), a maned wolf (Chrysocyon brachyurus), and a hoary zorro (Lycalopex vetulus) had positive serological results without clinical signs.

Non-complicated retinal detachment management: variations in 4 years. Retina 1 project; report 1

AIMS

To assess variations in the characteristics and management of two series of non-complicated rhegmatogenous retinal detachments (RD) carried out 4 years apart in Spain.

METHODS

Prospective, multicentric, non-randomised comparative study. 339 consecutive cases of RD treated in five hospitals were included. Group 1 (G1) (n = 186) included cases operated on from 1999 to 2001; group 2 (G2) (n = 153) included cases from 2004 to 2006. 83 variables related to preoperative characteristics of RD, surgical management and postoperative evolution were recorded. Surgeons were allowed to treat patients following their personal criteria. Differences in preoperative characteristics, rate of vitrectomy and anatomical outcome were studied. Quantitative variables were compared by Mann-Whitney U test and qualitative variables by standard contingency tables. Multivariate analysis was carried out by logistic regression analysis.

RESULTS

G1 showed a significantly longer delay in performing surgery, since the first symptoms appeared (G1: 29 (SD 50) days; G2: 22 (55); p<0.001) and more RD without visible retinal break than G2 (G1: 17.4%; G2: 9.2%; p = 0.028). In G2, cases with multiple retinal breaks (G1: 31.6%; G2: 44.6%) were more frequent (p = 0.022). No significant differences in other preoperative variables were observed. Vitrectomy was performed in 30.1% in G1 and in 78.4% in G2 as a primary surgical approach (p<0.001). Regardless of the characteristics of the RD, the rate of vitrectomy was higher in G2. The reattachment rate was over 94% in both groups (p = 0.833). Pseudophakic RD showed better anatomical outcomes in G2 (G1: 83.9%; G2: 96.4%; p = 0.028).

CONCLUSION

There is an increasing tendency to treat RD with primary vitrectomy, which is related to neither a higher complexity of cases nor better anatomical results.

The progression of coronary artery calcification in predialysis patients on calcium carbonate or sevelamer

Coronary artery calcification is more prevalent in dialysis patients than in patients without kidney disease and this is associated with high serum phosphorus. In this study, we evaluate the effect of calcium carbonate or sevelamer treatments on the progression of calcification in 90 predialysis patients. Inclusion criteria were stable serum calcium, phosphorus, parathyroid hormone, and a similar baseline total calcium score (TCS). These patients were not treated by phosphate binder, vitamin D, or statin. They were given low-phosphorus diets without or with daily calcium carbonate or sevelamer throughout the study that averaged 2 years. Baseline demographic or clinical characteristics along with biochemical parameters were not different among the three groups. The TCS significantly increased in patients on the low-phosphorus diet alone, to a lesser extent in calcium carbonate-treated patients, and not at all in sevelamer-treated patients. The progression of coronary calcification paralleled that of the calcium score. Our study shows that sevelamer treatment should not be restricted to dialysis patients; however, a larger study should be undertaken to confirm these results.

Serologic evidence of Leishmania infection in free-ranging wild and domestic canids around a Brazilian National Park

Transmission of disease between wildlife, domestic animals, and humans is of great concern to conservation issues and public health. Here we report on the prevalence of anti-Leishmania sp. antibodies in 21 wild canids (7 Chrysocyon brachyurus, 12 Cerdocyon thous, and 2 Lycalopex vetulus) and 74 free domestic dogs (Canis familiaris) sampled around the Serra do Cipó National Park. In dogs, the apparent prevalence was 8.1% and in wild canids it was 19% (2 crab-eating foxes, C. thous, and 2 maned wolves, C. brachyurus). Management of the domestic dog population with evaluation of incidence changes in humans and wildlife, and enlightenment on the role of wild reservoirs are essential issues for future action and research.

Interaction between surgical procedure for repairing retinal detachment and clinical risk factors for proliferative vitreoretinopathy

PURPOSE

To asses risk factors of proliferative vitreoretinopathy (PVR) and a model for predicting it.

METHODS

Observational, case-control. 335 patients with non-complicated retinal detachment (RD) were included: 134 developed PVR (Cases); 201 patients did not (Controls). Risk factors for PVR were identified by multivariate analysis. Influence of variables was assayed according to the surgical approach. By logistic regression analysis a model to predict the risk of developing PVR and odds ratio (OR) values for each clinical factor were estimated.

RESULTS

Risk was higher in patients > 70 years and with intraocular pressure lower than 14 (OR: 3.84; CI 95%: 2.04-7.30) and in retinal breaks larger than "1 clock hour" (OR: 2.54; CI: 1.28-5.05), extended retinal detachments (OR: 4.01; CI: 1.98-8.10) and reinterventions (OR: 1.55; CI: 1.14-9.22). Scleral surgery also was a risk factor (OR: 3.89; CI: 2.12-7.14) and aphakia/pseudophakia when scleral surgery is performed (OR: 3.33; CI: 1.54-7.22). A model to predict PVR was proposed with these results.

CONCLUSIONS

Surgical approach modifies risk factors of PVR, and should be taken into account to improve the models for predicting it.

[Clinical risk factors for postoperative proliferative vitreoretinopathy (PVR). A prospective study]

PURPOSE

To identify clinical risk factors for development of postoperative PVR, to determine the incidence of this complication and its time of onset by a prospective multicentric study.

METHODS

A multicentric and prospective study of 223 patients with rhegmatogenous retinal detachment (RD) was conducted. Logistic regression analysis was used to identify risk factors for PVR among 83 variables related to preoperative, intraoperative and postoperative characteristics.

RESULTS

22 out of 223 RD developed PVR (incidence 9.9%, confidence interval 95%: 5.9-13.9). After logistic regression analysis, four variables showed an odds ratio higher than 1.0 (RD affecting 4 quadrants, cryopexy, aphakia/pseudophakia and those RD in which an encircling band was implanted). None of these factors showed a <<p>> value lower than 0.05. Most of postoperative PVR (77.2%) appeared in the first month after surgery.

CONCLUSIONS

This study establishes the incidence of PVR, and its time of onset, but it was not effective to identify clinical risk factors with a high level of confidence.

[Comparison of different techniques for cytologic analysis of vitreous specimens]

PURPOSE

To assess the efficacy of four methods to study the cytology of vitreous samples, and to evaluate the most efficient for routine analysis and immunocytochemical staining.

METHODS

Diluted and undiluted vitreous samples of 87 consecutive patients suffering vitreoretinal surgery for different diseases were analysed. The specimens were centrifugated and then processed through four different procedures: agar sandwich (29 cases), direct paraffin embedding (33 cases), cytospin preparations (82 cases) and cytoblock (8 cases).

RESULTS

Evaluable material was obtained in: agar sandwich 18 out of 29 cases (62%), direct paraffin embedding 32 out of 33 cases (96.9%), cytospin 72 out of 82 cases (87.8%) and cytoblock 1 out of 8 cases (12.5%).

CONCLUSIONS

Direct paraffin embedding and cytospin are the most efficient procedures for routine purposes. Agar sandwich technique seems to be useful for studying small pieces of tissue. Direct paraffin embedding and agar sandwich technique seems to be valuable for immunocytochemistry. After 8 cases processed with cytoblock, our experience did not show valuable results for processing vitreous samples.

Frequency and determinants of microalbuminuria in mild hypertension: a primary-care-based study

OBJECTIVE

To evaluate the frequency of microalbuminuria and its relationship with several risk factors and left ventricular mass in a population of mildly hypertensive subjects attended in a primary-care setting.

DESIGN

Cross-sectional study.

SETTING

Eight primary-care centres.

PATIENTS

Two hundred and twenty-three non-diabetic patients recently diagnosed with mild hypertension were included in the study. None of them had clinical evidence of target-organ damage or had received prior antihypertensive treatment.

INTERVENTIONS

Subjects included in the study underwent clinical interview, measurement of blood pressure (BP) on three visits, blood analysis, measurement of albumin by immunonephelometry in three overnight urine collections, 24 h BP monitoring and M-mode and Doppler echocardiography.

MAIN OUTCOME MEASURES

Tobacco habit, clinic BP, body mass index, serum lipids and uric acid, glycaemia, urinary albumin excretion (UAE), ambulatory BP and left ventricular mass index.

RESULTS

The frequency of microalbuminuria was 7.2%. Microalbuminuric patients were more likely to be men and to be characterized by higher ambulatory BP, body mass index and uric acid levels. Regression analysis demonstrated that male sex and 24 h systolic BP were determinants of UAE. Patients with white-coat hypertension showed lower UAE than did subjects with sustained hypertension. Although a certain relationship between UAE and left ventricular mass index was found, these variables were not significantly correlated.

CONCLUSIONS

A low proportion of mildly hypertensive patients attended in a primary care setting are microalbuminuric. In this population, UAE is an expression of BP values over 24 h and correlates with several risk factors.

[Chromosome 22 (22q.11.2) deletion. Etiology of conotruncal heart abnormalities]

Important advances in the diagnosis and treatment of congenital heart disease (CHD) have been made in the past 50 years. Nowadays echocardiogram plays an important role in the diagnosis. This procedure is able to identify a wide range of malformations. Cardiac catheterization is mainly a therapeutic tool, surgery is now performed much earlier because CHDS are diagnosed sometimes before birth or very early in life. All this advances in the diagnosis and treatment of this group of patients, allows them not only a better quality of life but also the possibility of reaching adulthood and having children. The study of the etiology of CHD is a field that has not evolved as fast as the assessment and treatment. Nowadays we have a larger population of adults with CHD. The discovery of a microdeletion of chromosome 22 q11.2 associated with conotruncal cardiac defects, proves a common etiology for clinical phenotypes and conotruncal malformations. In order to identify, which of these patients share the same etiology and presented with this syndrome, we collected a group that shared not only heart defects of the conotruncal type but also specific phenotypic alterations such as broad nasal bridge, nasal dimple, high palate, and digitalization of the first finger among others. The first two patients studied with FISH technique were positive to monosomy of a locus on chromosome 22. Those patients with CHD of conotruncal type should undergo microdeletion testing so genetic counseling can be offered as well as appropriate treatment in areas such as cardiology and developmental psychology.

Cholinergic modulation of neostriatal output: a functional antagonism between different types of muscarinic receptors

It is demonstrated that acetylcholine released from cholinergic interneurons modulates the excitability of neostriatal projection neurons. Physostigmine and neostigmine increase input resistance (RN) and enhance evoked discharge of spiny projection neurons in a manner similar to muscarine. Muscarinic RN increase occurs in the whole subthreshold voltage range (-100 to -45 mV), remains in the presence of TTX and Cd2+, and can be blocked by the relatively selective M1,4 muscarinic receptor antagonist pirenzepine but not by M2 or M3 selective antagonists. Cs+ occludes muscarinic effects at potentials more negative than -80 mV. A Na+ reduction in the bath occludes muscarinic effects at potentials more positive than -70 mV. Thus, muscarinic effects involve different ionic conductances: inward rectifying and cationic. The relatively selective M2 receptor antagonist AF-DX 116 does not block muscarinic effects on the projection neuron but, surprisingly, has the ability to mimic agonistic actions increasing RN and firing. Both effects are blocked by pirenzepine. HPLC measurements of acetylcholine demonstrate that AF-DX 116 but not pirenzepine greatly increases endogenous acetylcholine release in brain slices. Therefore, the effects of the M2 antagonist on the projection neurons were attributable to autoreceptor block on cholinergic interneurons. These experiments show distinct opposite functions of muscarinic M1- and M2-type receptors in neostriatal output, i.e., the firing of projection neurons. The results suggest that the use of more selective antimuscarinics may be more profitable for the treatment of motor deficits.

Ebstein's anomaly. Clinical profile in 174 patients

The study population consisted of 148 patients who did not undergo surgical treatment and 26 who were operated, most of them diagnosed after the age of 2, with a follow-up from 6 months to 25.3 years. Patients were divided in three groups of clinical deterioration according to their functional class and cardiothoracic index (CTR) long-term follow-up in 148 nonoperated patients showed significant differences for mortality between groups I and III (p < 0.001), and between groups II and III (p < 0.02). Predictors of death included the association among functional class III or IV CTR > or = 65% with either cyanosis or arrhythmias (p < 0.05). The multivariate analysis showed that clinical deterioration (p < 0.0001), CTR (p < 0.0002) and functional class (p < 0.001), were significant for mortality. Kaplan-Meier analysis showed a survival rate of 81% in the overall patients free from surgical treatment. According to Kaplan-Meier analysis, the rate of survival was lower in patients with CTR > or = 65% (63.5%), in patients who had functional class IV (52.5%) and in patients included in group III of clinical deterioration (38.2%). Despite the fact that the association of functional class III or IV plus CTR > or = 65% with either cyanosis or arrhythmias is a good predictor for death, the mortality in patients who had only one of these variables was lower. Patients included in group II of clinical deterioration in stable condition presented long survival with medical treatment. Due to the high mortality rate found in group III, surgical treatment of Ebstein's anomaly must be done before deteriorating into group III. Surgical indication must be done considering the surgical risk of each group according to the experience of the Institution and comparing the rate of surgical mortality with the rate of survival without surgery.

[Truncus arteriosus communis and interrupted aortic arch]

The association between persistent truncus arteriosus and interrupted aortic arch is a rare but important condition since it has special clinical and therapeutic implications. In this article we present three cases with this malformation. The clinical characteristics are similar to patients with isolated truncus such as heart failure and cyanosis since birth, a protosystolic click, an ejection murmur over the left parasternal line, heart enlargement, increased pulmonary vascular markings and biventricular hypertrophy. The clinical suspicion of interrupted aortic arch is bases on the presence of asymmetric pulses in the upper and lower limbs, but this difference is present only when the arterial duct is restrictive. Because of that, the echocardiographic analysis, mainly, and the angiocardiogram, secondarily, are very important diagnostic tools. We analyze the echocardiographic diagnostic findings, as well as the angiocardiographic anatomy. Also, some important pathophysiological aspects are discussed.

Modulation transfer functions of eyes implanted with intraocular lenses

An experimental study of the retinal image quality in aged subjects after their eyes have been implanted with intraocular lenses (IOL's) has been performed. The method is based on recording in vivo the aerial image of a point test, after a double pass through the ocular media, and subsequent computation of the eye's modulation transfer function. The optical performance of three different types of bifocal IOL is compared with that of conventional monofocal IOL's. The results show that eyes implanted with bifocals exhibit a mean reduction in the modulation transfer function (contrast in the retinal image) of a factor of 2, while keeping a resolution similar to that of monofocal IOL's (which explains why visual acuities are also similar in these two cases). The mean retinal image modulation in eyes implanted with monofocal IOL's is ∼2.5 times lower than that obtained with young emmetropic subjects, but it seems to be similar to that corresponding to # of persons of the same age (∼60 years) normal eyes.

Effects of aging in retinal image quality

The retinal image quality characterized by the modulation-transfer function of the eye was measured for two groups of subjects aged in the late twenties and mid sixties, respectively. In both groups, we obtained modulation transfer functions by using a double-pass method under the same experimental conditions: 4-mm artificial pupil, paralyzed accommodation, and objective control of the refractive state and centering. Results showed lower values of modulation in the retinal image for older subjects compared with the younger subjects. The modulation transfer function ratio is similar to that previously found for contrast-sensitivity measurements with subjects in the same age groups. These results suggest that a significant fraction of the loss in spatial vision with age has an optical origin. Apart from the well-known increase in intraocular scattering, there also appears to be an increment in ocular aberration that causes an additional reduction in the contrast of retinal images.

[Keratitis caused by Pseudomonas aeruginosa and secondary endophthalmitis]

We report three patients with Pseudomonas aeruginosa keratitis. Two patients in the Intense Care Unit had exogenous bacterial endophthalmitis assessed by histopathology; the infection had probably a nosocomial origin and the outcome was fatal. The third case was associated with the use of soft contact lenses and even though clinically endophthalmitis was suspected there was a favourable response to treatment. We review diagnostic aspects and discuss the management of bacterial keratitis and endophthalmitis.

[Comparative study of 2 mechanical mitral valves]

We present the long term follow-up of two groups of patients under 16 years of age in whom two different types of mitral valve prostheses were used for the treatment of mitral valve disease. Group I was formed by 74 patients with Starr-Edwards (6120) prosthesis and group II by 36 cases with Bjork-Shiley prosthesis. Group I was followed for a mean period of 11 years and group II for a mean period of 7.5 years. The clinical evolution of both groups assessed according to the New York Heart Association criteria showed improvement of the functional class (p less than 0.006). Twenty seven cases of group I and 21 of group II underwent cardiac catheterization for the evaluation of surgical results. In group I, the mean pulmonary arterial systolic pressure (PASP) decreased from 57 mmHg to 33 mmHg (p less than 0.001) and the mean pulmonary arterial wedge pressure (PAWP) from 20.8 mmHg to 12.1 mmHg (p less than 0.05). In group II, the mean PASP decreased from 59.2 mmHg to 28.5 mmHg (p less than 0.001) and the mean PAWP from 24.6 mmHg to 8.5 mmHg (p less than 0.001). There was statistically significant difference for a greater incidence of thromboembolism in group I (p = 0.037). No differences were found for bacterial endocarditis, dysfunction and death.

Cutis marmorata telangiectatica congenita and glaucoma

A case of cutis marmorata telangiectatica congenita (CMTC) is described in association with congenital glaucoma. Approximately 68 cases of CMTC and only four cases associated with glaucoma have been reported. The type of glaucoma seems to be related to an abnormality of the filtration in the anterior angle, due to increased pressure in the episcleral vessels. The surgical treatment is trabeculectomy, and opening an alternative drainage pathway.