Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

P196 CHANGE IN THE DAILY HOSPITALIZATION RATE FOR ACUTE MYOCARDIAL INFARCTION IN THE VENETO REGION FROM 2006 TO 2018

Background

Acute myocardial infarction (AMI) continues to represent the leading cause of cardiovascular mortality in Italy, with important prognostic and health consequences both in the short and long term. The aim of the study is to evaluate the long–term variation in the daily hospitalization rate for AMI in the Veneto region.

Materials and Methods

Data regarding the total number of hospitalizations due to AMIbetween 2006 and 2018 were extracted from the periodic epidemiological reports of the Veneto region which can be consulted on the website www.ser–veneto.it and then re–elaborated and analyze. In particular, changes in daily hospitalization rates for AMI were calculated, then sub–classified into AMI with ST–segment elevation myocardial infacrction (STEMI) and without (NSTEMI). The trend of change in daily hospitalization rates was assessed with the Jonckheere–Terpstra test, using the SPSS statistical software version 19.0 (SPSS; SPSS Inc., USA).

Results

During the study period, in the Veneto region 87,490 hospitalizations for AMI [48,165 (55.0%) STEMI and 32,325 (45.0%) NSTEMI], of which 75.7% were managed in Cardiology / ICU wards were registered. The overall average daily hospitalization rate for AMI over the entire period was 18.3 ± 0.6 admissions / day [range 17.5 / 19.8] with a decrease of 11.4% / year (p = 0.009). Among these, patients admitted for STEMI were hospiutalized for 10.1 ± 1.2 / day [range 8.6–12.4]; however their daily hospitalization rate decreased by 32.4% / year (p < 0.001). Conversely, 8.2 ± 0.8 patients with NSTEMI / day were hospitalized in the observation period [range 7–8.9]. showing a growing hospitalization trend in the period considered (+ 20.9% / year, p < 0.001) (Figure 1).

Conclusions

The daily hospitalization rate for AMI in the Veneto region has overall decreased in recent years, however, there has been a significant increase in daily hospitalizations for NSTEMI. The high number of daily hospitalizations requires close synergy between the cardiology departments of the region in order to ensure adequate care for patients with acute cardiac events in the area.

Clinical characteristics, management and outcomes in patients with new onset or worsening acute heart failure enrolled in the nationwide BLITZ-HF study

Background

Real world observational clinical data is important to better characterize heterogeneous groups of patients, such those with acute heart failure (AHF), in order to phenotype patients with different prognosis and to generate hypotheses regarding management in clinical practice or patient selection for planning randomised clinical trials.

Aims

To describe clinical characteristics, management and outcomes of acute heart failure (AHF) patients admitted for a first HF episode (de novo) or for worsening chronic HF (WHF) and enrolled by Italian cardiology sites participating to the nationwide BLITZ-HF study.

Methods

BLITZ-HF was a prospective nationwide study based on a web-based recording system used during two enrollment periods (08/03/2017 – 04/09/2017 and 24/12/2017 – 09/04/2018). Overall, 7218 patients with acute and chronic HF were enrolled by 106 sites.

Results

The present analysis refers to the 1470 out of 1494 patients admitted for AHF not lost to follow-up, of which 822 (56%) presented with de novo and 648 (44%) with WHF. Patients were followed for a median of 370 days [IQR 339–395]. Mean age was significantly higher in patients with WHF 74±12 (vs 72±12 in de novo, p<0.001), while no gender differences were observed (WHF 35% vs de novo 36%). Compared to de novo, patients with WHF had more frequently a history of treated hypertension (66% vs 61%, p=0.028), atrial fibrillation (52% vs 29%, p<0.0001), previous myocardial infarction and coronary revascularization (41% vs 19% and 38% vs 18% respectively, both p<0.0001), a previous device implantation (34% vs 6%, p<0.0001). Non cardiac comorbidities such as CKD and COPD resulted in a higher rate among patients with WHF (51% vs 28% and 26% vs 17%, both p<0.0001). We also found significant differences between the two groups in terms HF ejection fraction categories (HFrEF 64.5% vs 52.3%, HFmrEF 13.9% vs 21.4%, HFpEF 21.6% vs 26.3%, for WHF vs de novo, p<0.0001). On admission, patients with WHF presented with lower systolic blood pressure (124±27 vs 135±28, p<0.0001), lower hart rate (87±23 vs 95±26, p<0.0001), higher creatinine levels (1.5±0.7 vs 1.3±0.8, p<0.0001). Both inotropes and high dose of IV furosemide (>150 mg) were more frequently used among WHF patients (22.8% vs 9.7% and 35.7% vs 19.7%, p<0.0001).

Figure and table show Kaplan-Meyer curves for one year all-cause mortality and detailed in-hospital and one-year outcomes regarding mortality (total and CV) and hospitalizations (all, CV and HF) as well as the combined outcome of HF hospitalization and all-cause mortality. Patients with WHF had significantly worse outcomes compared to those with de novo HF.

Conclusions

In our study we confirm the heterogeneity of AHF patients and the importance of identify and characterize different subgroups. Patients with WHF have a more severe clinical profile and worse in-hospital and one-year clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study was funded by Heart Care Foundation with a partial unrestricted support from Abbott, Daiichi Sankyo, Medtronic, Servier, Vifor.

Diagnostic accuracy of proton magnetic resonance spectroscopy and perfusion-weighted imaging in brain gliomas follow-up: a single institutional experience

Objectives The objective of this study was to evaluate whether proton magnetic resonance spectroscopy and perfusion magnetic resonance imaging (MRI) are able to increase diagnostic accuracy in the follow-up of brain gliomas, identifying the progression of disease before it becomes evident in the standard MRI; also to evaluate which of the two techniques has the best diagnostic accuracy. Methods Eighty-three patients with cerebral glioma (50 high-grade gliomas (HGGs), 33 low-grade gliomas (LGGs)) were retrospectively enrolled. All patients underwent standard MRI, H spectroscopic and perfusion echo-planar imaging MRI. For spectroscopy variations of choline/creatine, choline/N-acetyl-aspartate ratio, and lipids and lactates peak were considered. For perfusion 2.0 was considered the cerebral blood volume cut-off for progression. The combination of functional parameters gave a multiparametric score (0-2) to predict outcome. Diagnostic performance was determined by the receiver operating characteristic curve, with sensitivity, specificity, positive predictive and negative predictive values. Results In patients with LGGs a combined score of at least 1 was the best predictor for progression (odds ratio (OR) 3.91) with 8.4 months median anticipation of diagnosis compared to standard MRI. The individual advanced magnetic resonance technique did not show a diagnostic accuracy comparable to the combination of the two. Overall diagnostic accuracy area under the curve (AUC) was 0.881. In patients with HGGs the multiparametric score did not improve diagnostic accuracy significantly. Perfusion MRI was the best predictor of progression (OR 3.65), with 6.7 months median anticipation of diagnosis. Overall diagnostic accuracy AUC was 0.897. Then spectroscopy and perfusion MRI are able to identify tumour progression during follow-up earlier than standard MRI. Conclusion In patients with LGGs the combination of the functional parameters seems to be the best method for diagnosis of progression. In patients with HGGs perfusion is the best diagnostic method.

Serodiscordance in chronic Chagas disease diagnosis: a real problem in non-endemic countries

According to the WHO, chronic Chagas disease (CD) diagnosis is based on two serological techniques. To establish a definitive diagnosis, the results must be concordant. In cases of discordances, the WHO proposes repeating serology in a new sample, and if results remain inconclusive, a confirmatory test should be performed. This study, conducted at two Tropical Medicine Units in Europe over 4 years, aims to assess the diagnostic yield of TESA- (trypomastigote excreted-secreted antigens) blot as a confirmatory technique in patients with inconclusive and discordant results. Of 4939 individuals screened, 1124 (22.7%) obtained positive results and 165 (3.3%) discordant results. Serology was repeated in 88/165 sera and discrepancies were solved in 25/88 (28.4%) cases. Patients without a definitive diagnosis were classified in two different groups: Group 1, including patients with inconclusive results despite retesting (n = 63), and Group 2, including patients with discordant results not retested (n = 77). TESA-blot was performed for all of Group 1 and 39/77 of Group 2 and was positive for 33/63 (52.4%) and 21/39 (53.8%), respectively. Analysis of Group 1 results showed a moderate agreement between results of the ELISA based on native antigen and TESA-blot (κ 0.53). In contrast, a clear disagreement was observed between the ELISA based on recombinant antigens and TESA-blot (κ <0). A sizeable proportion of patients are suspected to have CD with inconclusive results or in whom re-testing is not feasible. TESA-blot was positive in half of these patients, highlighting the need for a confirmatory assay in European centres caring for exposed individuals.

Neuromyelitis optica: atypical clinical and neuroradiological presentation

The extreme variability of clinical and MRI findings in the suspicion of Devic's disease always requires the detection of specific antibodies (AQP4). MRI scans were performed with a high-field MRI scanner (1.5T General Electric Signa Horizon): the MRI protocol of the brain employed axial DP, T2, T1, FLAIR and DWI weighted images (wi) and coronal T2-wi. After intravenous administration of contrast medium axial and sagittal T1-weighted images of the brain were repeated. The spine protocol employed after contrast medium included sagittal T2-wi, T2-wi with fat suppression and T1-wi. In May 2004, a 64-year-old healthy Caucasian woman began to suffer loss of motor and thermal sensitivity in the left lower limb. MRI showed non-specific areas of abnormal signal intensity on the deep left frontal and right frontoparietal white matter with no pathological enhancement after contrast medium and a small intramedullary area of altered signal at metameric level C2-C4 with a diagnosis of post-viral transverse myelitis. The patient had two similar episodes years later so the neurologist decided to search for circulating IgG AQP4 with the definitive diagnosis of neuromyelitis optica. In this case, compared to a clinical presentation of atypical deficit neurological involvement, the neuroradiological results of a progressive diffuse involvement of the white matter were atypical.

Progressive Multifocal Leukoencephalopathy Following Treatment with Rituximab in an HIV-Negative Patient with Non-Hodgkin Lymphoma. A Case Report and Literature Review

Progressive multifocal leukoencephalopathy (PML) is a rare rapidly progressive demyelinating disease of the central nervous system caused by reactivation of latent John Cunningham (JC) polyomavirus (JCV) infection. We describe an unusual case of PML in a 54-year-old patient with follicular non-Hodgkin lymphoma who received rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovicin and prednisolone (R-CHOP) therapy. She started to notice gradual progressive neurological symptoms about two months after completion of rituximab treatment and was therefore admitted to hospital. On admission, brain CT and MRI showed widespread lesions consistent with a demyelinating process involving the subcortical and deep white matter of the cerebral and cerebellar hemispheres. CT and MRI findings were suggestive of PML, and JC virus DNA was detected by polymerase chain reaction assay of the cerebrospinal fluid and serum. The patient was treated supportively but reported a progressive worsening of the clinical and radiological findings. Our report emphasizes the role of CT and MRI findings in the diagnosis of PML and suggests that PML should be considered in patients with progressive neurological disorders involving the entire nervous system and mainly the white matter, especially in the presence of previous immunomodulatory treatment or immunosuppression.

Pediatric inflammatory diseases. Part I: multiple sclerosis

Multiple sclerosis (MS) is an inflammatory CNS disease characterized by multifocal areas of demyelination; usually it arises in young adults, but can also occur in children (under the age of 10) and adolescents (under the age of 18). As in adult, pediatric MS (PMS) diagnosis is based on the demonstration of multiple demyelination episodes separated in time and spaces. Diagnostic criteria realized for childhood are similar to those employed for adults. Although clinical and imaging features of PMS can be similar to those of adults, the disease is often characterized by a more aggressive course and atypical imaging findings, with giant and pseudotumoral plaques. Differential diagnosis between PMS and ADEM could be difficult: clinical findings and MRI are necessary; sometimes MRI follow-up is required for definitive diagnosis.

Chagas disease in Italy: breaking an epidemiological silence

Chagas disease, a neglected tropical disease that due to population movements is no longer limited to Latin America, threatens a wide spectrum of people(travellers, migrants, blood or organ recipients,newborns, adoptees) also in non-endemic countries where it is generally underdiagnosed. In Italy, the available epidemiological data about Chagas disease have been very limited up to now, although the country is second in Europe only to Spain in the number of residents from Latin American. Among 867 at-risk subjectsscreened between 1998 and 2010, the Centre for Tropical Diseases in Negrar (Verona) and the Infectious and Tropical Diseases Unit, University of Florence found 4.2% patients with positive serology for Chagas disease (83.4% of them migrants, 13.8% adoptees).No cases of Chagas disease were identified in blood donors or HIV-positive patients of Latin American origin. Among 214 Latin American pregnant women,three were infected (resulting in abortion in one case).In 2005 a case of acute Chagas disease was recorded in an Italian traveller. Based on our observations, we believe that a wider assessment of the epidemiological situation is urgently required in our country and public health measures preventing transmission and improving access to diagnosis and treatment should be implemented.

Chagas disease in Italy: breaking an epidemiological silence

Chagas disease, a neglected tropical disease that due to population movements is no longer limited to Latin America, threatens a wide spectrum of people (travellers, migrants, blood or organ recipients, newborns, adoptees) also in non-endemic countries where it is generally underdiagnosed. In Italy, the available epidemiological data about Chagas disease have been very limited up to now, although the country is second in Europe only to Spain in the number of residents from Latin American. Among 867 at-risk subjects screened between 1998 and 2010, the Centre for Tropical Diseases in Negrar (Verona) and the Infectious and Tropical Diseases Unit, University of Florence found 4.2% patients with positive serology for Chagas disease (83.4% of them migrants, 13.8% adoptees). No cases of Chagas disease were identified in blood donors or HIV-positive patients of Latin American origin. Among 214 Latin American pregnant women, three were infected (resulting in abortion in one case). In 2005 a case of acute Chagas disease was recorded in an Italian traveller. Based on our observations, we believe that a wider assessment of the epidemiological situation is urgently required in our country and public health measures preventing transmission and improving access to diagnosis and treatment should be implemented.

Dynamic angio-MRI demonstration of persistent left superior vena cava in the absence of the right superior vena cava

This condition is a rare anomaly. Combination with other congenital malformations including coarctation of the aorta, double aortic arc, transposition of great vessels and dextrocardia was reported. We performed an MRI evaluation. MRI was first obtained at cardiac level using a gated Black Blood and Cine technique, useful to confirm the enlarged coronary sinus, and then using a dynamic angiographic technique. By means of the latter modality, each frame was obtained in 5 s and was useful to demonstrate the contrast bolus through the venous, cardiac, pulmonary and systemic levels. It was possible to demonstrate the persistence of the left superior vena cava in the absence of the right superior vena cava.

Outbreak of imported trichinellosis in Verona, Italy, January 2008

We describe an outbreak of trichinellosis in Verona, Italy, in early 2008 that was imported from Romania.

Enhanced Levels of Oxidized Low-Density Lipoprotein Prime Monocytes to Cytokine Overproduction via Upregulation of CD14 and Toll-Like Receptor 4 in Unstable Angina

OBJECTIVES

The purpose of this study was to establish whether oxidized low-density lipoprotein (oxLDL) contributes to cytokine overproduction via upregulation of CD14 and toll-like receptor-4 (TLR-4) expression on circulating monocytes of unstable angina (UA) patients.

METHODS AND RESULTS

Expression of CD14 and TLR-4 on circulating monocytes, and the concentration of plasma oxLDL, (interleukin [IL])-6, IL-1 beta, IL-8, tumor necrosis factor (TNF)-alpha, monocyte chemoattractant protein-1 (MCP-1) were measured in 27 control (C) subjects, 29 patients with stable angina (SA), and 27 with UA. CD14 and TLR-4 expression on monocytes and circulating IL-6, IL-1 beta, and oxLDL were higher in UA than in SA and C subjects (P<0.001). In in vitro experiments, oxLDL increased CD14 and TLR-4 expression (P<0.001) in control monocytes as well as IL-6, IL-1 beta, and at a lower extent TNF-alpha and MCP-1 levels in the supernatant (P from <0.05 to <0.001). The preincubation of sera derived from UA patients but with control monocytes also induced a significant increase of CD14 and TLR-4 expression (P<0.001) and of IL-6 and IL-1 beta production (P<0.001) in the supernatant.

CONCLUSIONS

In UA patients oxLDL may contribute to monocyte overproduction of some cytokines by upregulating CD14 and TLR-4 expression.

[Acute cholangitis caused by choledocholithiasis: traditional surgery or endoscopic biliary drainage]

BACKGROUND

Endoscopic drainage of the biliary tree for acute cholangitis is a therapeutic modality with a lower mortality and complication rates.

AIM

To compare endoscopic drainage with surgical treatment in the emergency management of acute cholangitis.

PATIENTS AND METHODS

Between 1995 and 1998, sixty five patients with acute cholangitis were subjected to an endoscopic drainage of the biliary tree. In the same period, 40 patients were treated with traditional surgical procedures. The evolution of both groups of patients were compared.

RESULTS

Sixty two patients (95.4%) subjected to endoscopic treatment had a satisfactory evolution, compared with 23 (58%) of those operated (p < 0.001). Five operated patients and no individual subjected to endoscopic drainage died (p < 0.01). Mean postoperative hospital stay of operated patients was 15.5 +/- 19.6 days compared to 5.8 +/- 4.2 days in those subjected to endoscopic drainage (p < 0.001). Definitive resolution of biliary obstruction was achieved in 83% of patients subjected to endoscopic drainage or traditional surgery.

CONCLUSIONS

Endoscopic drainage has a lower rate of complications and mortality than traditional surgery, in the treatment of acute cholangitis.

Left atrial overload can be used to estimate mitral regurgitant volume

This study was conducted to assess the accuracy of the estimated mitral regurgitant volume using both the left atrial filling volume and the systolic component of pulmonary vein flow expressed as the percent of its total. Since mitral regurgitation fills the left atrial chamber, the variation in atrial volume during ventricular systole has been proposed as a means to evaluate the severity of regurgitation. Although the correlation with invasive grading of mitral regurgitation is good, there is an unacceptable overlap among grades caused by the absence of information concerning pulmonary vein flow, which enters the left atrium while regurgitation occurs. The Doppler regurgitant volume, or Dp-RVol (mitral stroke volume minus aortic stroke volume) was quantified in 74 patients with any degree and etiology of mitral regurgitation. Atrial volumes were measured from the four-chamber apical view (biplane area-length method). The systolic time-velocity integral of pulmonary vein flow was expressed as the percent of the total (PVs%) (systolic-diastolic) time-velocity integral. These parameters were subjected to multivariate analysis and a regression equation was obtained. The equation was subsequently applied to a group of 31 patients without mitral regurgitation, as evaluated by color Doppler or continuous-wave Doppler and to the overall population (105 patients) in order to estimate the mitral regurgitant volume. In 74 patients with mitral regurgitation, the Doppler regurgitant volume was univariately correlated with the left atrial filling volume (r= 0.74; p<0.0001) and the systolic pulmonary vein velocity integral expressed as the percent of the total (r=0.67; p<0.0001). In multiple regression analysis, the combination of atrial filling and the pulmonary vein velocity integral provided the more accurate estimation of the regurgitant volume (R2=0.84; standard error of the estimate [SEE], 13.9 mL; p<0.0001; Dp-RVol equals 7.84+[1.08*left atrial filling volume] 2 [0.839*PVs%]). In 31 patients with no mitral regurgitation detected by color Doppler or continuous wave Doppler the estimated regurgitant volume was 4.3±6.6 mL. In the overall population the estimated regurgitant volume and the Doppler regurgitant volume correlated well with each other (R2=0.85; SEE, 11.5 mL; p<0.0001). The equation was 100% sensitive and 98% specific in detecting a regurgitant volume higher than 55 mL. The combination of the atrial filling volume and the systolic pulmonary vein time-velocity integral expressed as the percent of the total allows reliable estimation of the regurgitant volume in patients with mitral regurgitation. (c)2001 CHF, Inc.

Prognostic implications of evaluation of contractile reserve in akinetic and hypokinetic segments during low dose dobutamine echocardiography in patients with acute myocardial infarction

BACKGROUND

Previous studies have reported the prognostic value of myocardial viability (MV) detected using low-dose dobutamine echocardiography (DbE). However, viability was frequently evaluated as improvement in regional wall motion score index, which includes increased function in hypokinetic segments, in which viable myocardium is necessarily present. It is not known whether an evaluation focusing on akinetic segments, in which the possible presence of viable myocardium is unknown, might have more prognostic value. The aim of this study was to compare the prognostic value of the improvement of myocardial function during dobutamine infusion in akinetic and hypokinetic regions in patients with acute myocardial infarction (AMI).

METHODS

191 patients with uncomplicated AMI and at least one akinetic segment were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using DbE. Myocardial viability was evaluated both as an increment in RWMSI (Delta RWMSI), which takes into consideration improvement in both akinetic and hypokinetic regions, and as an improvement of function in akinetic (Delta akinetic) and hypokinetic (Delta hypokinetic), segments considered separately. Follow-up evaluation was performed at 30+/-13 months.

RESULTS

On the basis of the Delta RWMSI, 94/191 patients were judged to have myocardial viability, whereas considering myocardial viability in akinetic segments only, 72/191 patients showed viability. At follow-up 18 patients had died (six viable considering Delta RWMSI; three viable considering Delta akinetic). The presence of a previous AMI, the site of AMI, RWMSI and the number of akinetic segments, and Delta RWMSI and Delta akinetic were related to mortality at univariate Cox analysis. At multivariate stepwise Cox regression analysis Delta akinetic, but not Delta hypokinetic proved to be significantly related to mortality. The Kaplan-Meier survival curves were no different in patients with or without viable myocardium evaluated as Delta RWMSI, while they were significantly different considering patients with or without viability in akinetic segments (P=0.04).

CONCLUSION

In conclusion our study confirms the prognostic importance of the evaluation of myocardial viability in infarcted patients. However, it points out that it is the presence of viability in akinetic segments that affects long-term survival in these patients. This supports the hypothesis that other mechanisms, above and beyond the effect on regional wall motion, are involved in the beneficial effects of myocardial viability.

Mitral regurgitation and left ventricular diastolic dysfunction similarly affect mitral and pulmonary vein flow Doppler parameters: the advantage of end-diastolic markers

Enhanced early mitral flow and reduced systolic pulmonary vein flow may be caused both by increased left ventricular pressure as the result of diastolic dysfunction and by increased transmitral flow as the result of mitral regurgitation. Nevertheless, Doppler parameters are widely used to predict left ventricular filling pressure. We aimed to analyze the interference of mitral regurgitation with Doppler parameters usually used to estimate left ventricular filling pressure and to identify markers independent of mitral regurgitation, which could reliably estimate increased left ventricular filling pressure. Eighty-four patients (age, 62 +/- 9 years; 82% men) had a complete echocardiographic Doppler examination. Transmitral E- and A-wave velocity, E deceleration time and A duration, pulmonary vein systolic and diastolic velocities, and reversal flow duration and maximal and minimal left atrial volumes were measured. The difference between the duration of pulmonary vein and mitral A waves was calculated (A'-A). Mitral regurgitant volume was quantitatively assessed by echocardiography. Left ventricular end-diastolic pressure was measured invasively. Patients had a wide range of left ventricular ejection fraction (14% to 70%), mitral regurgitant volume (0 to 94 mL), and left ventricular end-diastolic pressure (3 to 37 mm Hg). E velocity, E/A, pulmonary vein systolic and diastolic, and systo-diastolic ratios were significantly and independently correlated with both left ventricular end-diastolic pressure and mitral regurgitant volume. A'-A showed a strong correlation with left ventricular end-diastolic pressure (r = 0.70; P <.0001), but the relation with mitral regurgitant volume was not significant (r = 0.19; P =.08). Mitral regurgitation affects the majority of Doppler parameters widely used to predict filling pressure but does not influence Ad'-Ad, which proved to be the strongest predictor of left ventricular end-diastolic pressure.

Relationship between mitral regurgitation and myocardial viability after acute myocardial infarction: their impact on prognosis

Mitral regurgitation (MR) after acute myocardial infarction (AMI) is an important prognostic factor. Although its mechanisms are still debated, ventricular remodeling probably plays an important role. Because myocardial viability (MV) in the infarct zone reduces infarct expansion and ventricular remodeling, it is also possible that its presence counteracts the development of mitral regurgitation in infarcted patients. To evaluate this issue 191 patients with uncomplicated AMI, wall motion abnormalities (akinesis) and semiquantitative evaluation of MR were retrospectively selected from those consecutively examined at our echo-laboratory to evaluate MV using low-dose dobutamine echocardiography (DbE). Follow-up evaluation was performed at 30+/-13 months. Seventy-nine patients had no MR; 86 patients had grade 1 MR, 11 patients had grade 2 MR, nine patients had grade 3 MR, and six patients had grade 4 MR. Patients with significant MR (>grade 1) were older (63+/-7 vs. 59+/-10 years, P=0.03), had lower reduction of RWMSI (DeltaRWMSI) during DbE (0.08+/-0.11 vs. 0.22+/-0.28, P=0.01), more stenotic vessels at coronary angiography (2.35+/-0.93 vs. 1.67+/-1.12, P=0.01), and more frequently had anterior-inferior AMI (P<0.0001); they also had a non-significant tendency to higher RWMSI (2.04+/-0.38 vs. 1.92+/-0.28, P=0.06). In a multivariate regression analysis, DeltaRWMSI proved to be significantly related to the grade of MR (P=0.02). Eighteen patients died during follow-up. Death was more frequent in patients with MR (10/165 vs. 8/26, P=0.0003). At multivariate stepwise Cox regression analysis both the extent of ventricular dysfunction and the presence of MR were significantly related to mortality (P<0.0001 and P=0.01, respectively); DeltaRWMSI showed a non-significant tendency to influence mortality (P=0.09). When MR was excluded from the multivariate analysis, DeltaRWMSI remained significantly related to mortality (P=0.05). In conclusion our study suggests that the presence of MV in infarcted patients influences the development of MR. This reduction of MR may be one of the mechanisms by which MV affects mortality after AMI and should be considered in all studies that evaluate MV after myocardial infarction.

Echocardiographic prediction of clinical outcome in medically treated patients with aortic stenosis

BACKGROUND

The onset of symptoms is crucial in the natural history of severe aortic stenosis. In contrast, the impact of the degree of valve obstruction and left ventricular dysfunction on clinical outcome in terms of progression of symptoms and mortality is undefined.

METHODS AND RESULTS

Between April 1989 and June 1996, 108 patients (75% male, aged 68.7 +/- 10.3 years) with pure and isolated aortic stenosis of at least moderate degree had a complete Doppler echocardiography. Left ventricular end-diastolic and end-systolic diameters, thickness of ventricular septum, mass and ejection fraction, and maximal instantaneous aortic gradient were measured. Patients were followed up through March 1999. Sixty-five patients who underwent aortic valve replacement were censored at the time of surgery. The end point was considered to be death or symptomatic progression (onset of new symptoms or worsening of symptoms). At the time of diagnosis 64 (59%) were in New York Heart Association (NYHA) class I-II and 44 (41%) in NYHA class III-IV. After a mean follow-up of 46 +/- 21 months 6 patients died and 45 had worsening of symptoms. Univariate predictors of clinical outcome (death and worsening of symptoms) included left ventricular end-diastolic diameter (hazard ratio 1.03, P =.08), left ventricular end-systolic diameter (HR 1.04, P =.012), and left ventricular septum thickness (HR 1.14, P =.009) but not the degree of aortic obstruction. Multivariate predictors of clinical outcome were left ventricular septum thickness (P =.016) and left ventricular end-systolic diameter (P =.008).

CONCLUSION

In patients with various degrees of aortic stenosis the rate of clinical outcome is predicted by left ventricular function and septum thickness. Therefore both the left ventricular and aortic valve gradients should be taken into account when choosing the timing of intervention.

Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction

AIM

To compare the predictive value of thallium-201 single photon emission computed tomography (SPECT) scintigraphy (Sci) and low-dose dobutamine echocardiography (Dob) in predicting late recovery of dysfunctioning myocardium in patients with recent, uncomplicated myocardial infarction (MI).

METHODS AND RESULTS

19 patients (18 male, aged 58+/-8 years) with recent MI and ejection fraction <50% (35.5+/-8.3%) underwent 5-15 microg/kg per min Dob, rest-redistribution Sci and coronary angiography, respectively, 14+/-6, 16+/-7 and 17+/-5 days after MI. On an eleven-segment ventricular model devised to compare Dob and Sci segment by segment, each dysfunctioning ventricular segment was considered viable if it showed recovery of mechanical function at the echocardiographic follow-up, performed 6.3+/-1.5 months after revascularization (five PTCA, five GABG) or medical therapy. Among the 104 dysfunctioning segments, of which 26 (25%) showed recovery at follow-up, Dob and Sci gave a concordant response in 50 (48%, k = 0.13), correctly predicting the recovery (or not) of function in 42. Forty-two of 54 discordant responses were due to segments judged viable only by Sci and which had no recovery at follow-up (of these 37 were akinetic or severely hypokinetic at baseline). At the segment-by-segment analysis, the sensitivity, specificity, and accuracy in predicting recovery of function at follow-up were, respectively, 69, 88 and 84% for Dob as against 88, 36 and 49% for Sci (P<0.001 for both specificity and accuracy, P=NS for sensitivity).

CONCLUSION

In patients with recent MI, the specificity of Dob in the detection of myocardium capable of late mechanical recovery is significantly higher with respect to Sci, whereas sensitivity is slightly, not significantly higher for the latter. It is conceivable that Sci detects viable myocardium even if it is transmurally limited to epicardial layers in segments with severely impaired mechanical function in which viability will not affect late recovery of function.

The role of myocardial viability in deriving benefit from reestablishing infarct-related artery flow after acute myocardial infarction

Early, sustained patency of the infarct-related artery (IRA) induces myocardial salvage, which preserves left ventricular (LV) function and mediates better long-term outcome. However, the time course and the mechanisms of muscle recovery after myocardial infarction are not completely understood. A large body of evidence suggests that most of the improvement occurs during the hospital phase and is related to early and sustained thrombolysis in myocardial infarction 3 flow in the IRA. Nevertheless, the relationship between IRA status and regional and global LV mechanics in the chronic phase of the disease remains controversial. Some late recovery may occur, either spontaneously or after revascularization, even in the absence of documented myocardial ischemia. The interplay between vessel patency, coronary flow grade and severity of the residual stenosis, and the presence of stunned or hibernating myocardium in the area at jeopardy may explain this delayed improvement. Although there seems to be a limited time window in which myocardium can be salvaged, timely testing for viability, particularly in patients with poor LV function, is justified even in a later phase of the disease to challenge potential cardiac recovery.

Long-term prognostic value of the stenosis of the infarct-related artery and the presence of viable myocardium in akinetic ventricular regions in infarcted patients

BACKGROUND

Recent studies have reported that adequate perfusion of the infarct-related artery improves survival in patients with myocardial infarction, independently of left ventricular pump function. However, it is not known whether or not this reduction in mortality is independent of myocardial viability within the infarct zone. The aim of this study was to evaluate the prognostic value of the patency of the infarct artery and the presence of myocardial viability in akinetic regions in patients with myocardial infarction.

METHODS

Low-dose dobutamine echocardiography was performed in 154 patients with recent or previous myocardial infarction and known coronary anatomy. In each patient three vascular regions were defined. Each akinetic region was considered viable if function improved during dobutamine echocardiography, and irrorated by a not stenotic akinetic area-related artery if the supplying vessel had a stenosis < 75% or had been successfully revascularized within 1 month of dobutamine echocardiography.

RESULTS

At follow-up of 34 +/- 14 months, 19 patients died of cardiac death. At univariate Cox analysis end-diastolic and end-systolic volumes, ejection fraction, previous myocardial infarction, regional wall motion score index, and stenosis of the akinetic area-related artery were related to mortality. At multivariate analysis, stenosis of the akinetic area-related artery remained a significant predictor of mortality (p = 0.04), with higher mortality (13/66 vs 6/88, p = 0.02) in patients with a stenotic akinetic area-related artery, without differences in ejection fraction (35 +/- 9 vs 34 +/- 10%). Mortality was lower in patients with myocardial viability if they had a not stenotic akinetic area-related artery (1/43 vs 4/21, p = 0.02), while no difference was found among non-viable patients, with or without stenosis of the akinetic area-related artery (5/45 vs 9/45).

CONCLUSIONS

The present study confirms the prognostic role of the patency of the infarct-related artery. However, it suggests that the lower mortality in patients with a patent artery supplying akinetic infarcted regions is related to the presence of myocardial viability in these regions.

Acute anterior myocardial infarction: increased dye intensity in the myocardial risk area after coronary angioplasty is associated with reduction of diastolic volumes

BACKGROUND

Myocardial perfusion in the risk area during the acute phase of myocardial infarction has been extensively investigated over the last few years. The so-called "no-reflow" or "low-reflow phenomenon" (absence of myocardial perfusion despite patency of the infarct-related coronary artery) was shown to correlate with worse postinfarction remodeling, in particular when myocardial contrast echocardiography was used. The aim of this study was to determine, during routine coronary angiography performed before and after coronary angioplasty (PTCA) during the acute phase of myocardial infarction, the existence of the no-reflow phenomenon and its relation with ventricular remodeling, by evaluating the dye video density in the myocardial risk area. This confirmation by a different diagnostic technique may serve to highlight the role of myocardial perfusion as an index of prognosis in the clinical setting of acute myocardial infarction.

METHODS

Twenty-six patients (23 males, 3 females, mean age 57 +/- 8.7 years) who underwent either rescue (n = 11, 42.3%) or primary PTCA, according to clinical indications, of the left anterior descending coronary artery during an acute anterior myocardial infarction and who did not have stenosis of the left circumflex or right coronary artery, were retrospectively selected from a 6 year intake. The extent of coronary stenosis was assessed using biplane quantitative coronary angiography, while end-diastolic and end-systolic volume indexes, together with regional wall motion, were computed from echocardiography performed in the first 24 hours and at 6 months. Patients were subdivided into two groups on the basis of dye video intensity in the risk area, as assessed from images obtained during left main coronary artery injections before and immediately after PTCA. It was used a subtraction technique (Group A: increased video intensity, n = 12; Group B: no change, n = 14), assuming that higher peak intensity reflects greater myocardial blood volume. Three patients in Group B with ineffective PTCA were excluded, so that the final number of considered patients was 11.

RESULTS

The distribution of rescue PTCA was similar in the two groups (7 in Group A vs 3 in Group B, p = 0.13) as were clinical characteristics and therapeutic regimen. There was a significant time * group interaction for end-diastolic volumes (-4.6 +/- 23% in Group A vs +22 +/- 22% in Group B, p = 0.029), whereas end-systolic volumes showed a tendency to greater dilation in Group B (+19 +/- 28% vs +0.9 +/- 31% in Group A), although this difference was not significant (p = 0.27). No interaction was evident for increase in the vessel area (+46 +/- 12.5% in Group A vs +43.2 +/- 13.6% in Group B, p = 0.99), or for extent of regional dysfunction (+3.08 +/- 10.9 chords in Group A vs -2.5 +/- 9.5 chords in Group B, p = 0.50).

CONCLUSIONS

The detection of myocardial blood volume in the risk area using dye video intensity during left main dye contrast injection, is useful to distinguish whether there is improved perfusion at the muscular level, following successful angioplasty of the infarct-related coronary artery. Lack of improved myocardial perfusion has an adverse effect on left ventricular volumes independently of coronary stenosis resolution and regional wall motion changes in the time.

Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy

A number of surgical techniques are commonly performed to control the symptoms of inferior turbinate hypertrophy unresponsive to medical treatment. We report long-term results in 382 patients randomly assigned to receive electrocautery (62), cryotherapy (58), laser cautery (54), submucosal resection without lateral displacement (69), submucosal resection with lateral displacement (94), and turbinectomy (45). Outcomes of objective test results from rhinomanometry, acoustic rhinometry, mucociliary transport time, and secretory immunoglobulin A levels were compared to the symptom scores before and yearly after surgical treatment. These data indicate that submucosal resection with lateral displacement of the inferior turbinate results in the greatest increases in airflow and nasal respiratory function with the lowest risk of long-term complications.

Dentin desensitizing effects of Gluma Alternate, Health-Dent Desensitizer and Scotchbond Multi-Purpose

PURPOSE

To evaluate the effects of topical applications of Gluma Alternate, a Gluma Desensitizer version with reduced glutaraldehyde content, Health-Dent Desensitizer and Scotchbond Multi-Purpose (SMP) on hypersensitive erosion/abrasion lesions.

MATERIALS AND METHODS

55 patients were included in the trial with at least three teeth each presenting severe sensitivity. From a total of 184 teeth, 69 were treated with Gluma Alternate, 58 with Health Dent and 51 treated SMP, serving as a control. Sensitivity was recorded as response to cold air stimulus prior to treatment, immediately after the topical application of the agents, and after 1 week, 1 month and 6 months.

RESULTS

Both Gluma Alternate and SMP showed significant reduction in sensitivity between pre- and postoperative pain scores (P < 0.05). The post-treatment sensitivity scores (0 and 1) were no different between 1 week and 6 months. In the Health-Dent group only 10 of the 58 teeth showed sensitivity reduction. For this reason the remaining 48 teeth received a "rescue treatment" with Gluma Desensitizer. At the end of the 6-month observation time, all teeth treated with Gluma Alternate, Gluma Desensitizer, and SMP showed no or very little dentin sensitivity.

Left atrial filling volume can be used to reliably estimate the regurgitant volume in mitral regurgitation

OBJECTIVES

The objective was to analyze the accuracy and diagnostic value of the estimated regurgitant volume of mitral regurgitation using 1) left atrial volume variation during ventricular systole (left atrial filling volume) and 2) the percent of systolic pulmonary vein velocity integral compared with its total.

BACKGROUND

Left atrial filling volume (LAfill), which represents the atrial volume variation during ventricular systole, has been used for the assessment of mitral regurgitation severity. A good correlation with invasive semiquantitative evaluation was found, but with an unacceptable overlapping among grades. The reason could be the absence of information concerning the contribution of blood entering into the left atrium from the pulmonary veins.

METHODS

Doppler regurgitant volume (Dpl-RVol) (mitral stroke volume - aortic stroke volume) was measured in 30 patients with varying degrees and etiological causes of mitral regurgitation. In each patient atrial volumes were measured from the apical view, using the biplane area-length method. The systolic time-velocity integral of pulmonary vein flow was expressed as a percentage of the total (systolic-diastolic) time-velocity integral (PVs%). These parameters were used in this group of patients to obtain an equation whose reliability in estimating Dpl-RVol was tested in a second group of patients.

RESULTS

In the initial study group, with linear regression analysis the following parameters correlated with Dpl-RVol: end-systolic left atrial volume (R2=0.37, p=0.0004); LAfill (R2=0.45, p < 0.0001); PVs% (R2=0.56, p < 0.0001). In multiple regression analysis the combination of LAfill and the percent of the systolic pulmonary vein velocity integral (PVs%) provided a more accurate estimate of regurgitant volume (R2=0.88; SEE 10.6; p < 0.0001; Dpl-RV=6.18 + (1.01 x LAfill) - (0.783 x PVs%). The equation was subsequently tested in 54 additional patients with mitral regurgitation with a mean Dpl-RVol 27+/-37 ml. Estimated regurgitant volume and Dpl-RVol correlated well with each other (R2=0.90; SEE 12.1; p < 0.0001). In the test population, the equation was 100% sensitive and 98% specific in detecting a regurgitant volume higher than 55 ml.

CONCLUSIONS

Left atrial filling volume and pulmonary vein flow give a reliable estimate of regurgitant volume in mitral regurgitation.

The extent of regional wall motion abnormalities identifies patients at risk of extensive left ventricular remodeling: implications for the design of post myocardial infarction trials

BACKGROUND

The FAMIS (Fosinopril in Acute Myocardial Infarction Study) was a multicenter, placebo-controlled, double-blind trial designed to evaluate the safety and the efficacy of fosinopril in reducing left ventricular enlargement after acute anterior myocardial infarction. We evaluated the echocardiographic examinations performed during the trial in order to assess the trend of the remodeling process over time and to evaluate the role of infarct size in identifying patients at risk of progressive left ventricular dilation.

METHODS

A complete echocardiographic examination was performed on admission, before discharge and three months later. Patients undergoing coronary bypass surgery or PTCA had a further examination prior to the procedure. The echocardiograms were analyzed at a central laboratory, and the end-diastolic and end-systolic left ventricular volumes were computed by using a modified Simpson's rule technique. Regional wall motion was evaluated using the centerline method, analyzing the left ventricular boundary along 100 chords perpendicular to the centerline constructed midway between the end-diastolic and the end-systolic contours. A quantitative infarct-size index was then computed according to the number of chords with a fractional shortening equal to or less than 5%.

RESULTS

Left ventricular end-diastolic and end-systolic volume index significantly increased over time (p < 0.0001); as a result, the stroke volume increased (p < 0.0001) but the ejection fraction did not change. Patients were then divided according to the three-month infarct-size index. For both end-diastolic and end-systolic volume, not only did larger infarcts had higher volumes, but there was also a greater increase from baseline to 3 months. Moreover, larger infarcts had a lower ejection fraction, with a further reduction over the three months, while smaller infarcts had higher values and an increase over time. An infarct-size index of 25 or larger allowed prospective identification at the baseline examination of patients at risk of subsequent left ventricular dilation.

CONCLUSIONS

In conclusion, patients at greatest risk of left ventricular dilation, namely those with larger infarct size, constitute a group that is worth considering for any therapeutic effort for reducing the remodeling process. These patients could in fact benefit from therapeutic strategies aimed at the reduction of left ventricular remodeling and should be studied in clinical trials.

Prognostic value of detection of myocardial viability using low-dose dobutamine echocardiography in infarcted patients

Revascularization can improve ventricular function in patients with viable myocardium, but whether and how the presence of viable myocardium affects prognosis of infarcted patients is still far from clear. Thus, 202 patients (173 men, 59 +/- 9 years old) with a previous or recent myocardial infarction (MI) and regional asynergies underwent low-dose dobutamine echocardiography (5-15 microg/kg per min) to assess myocardial viability and were followed for a period of 16 +/- 11 months after revascularization (89 patients) or medical therapy (113 patients). Four groups of patients were defined: (1) patients with viability, revascularized (n = 64); (2) patients with viability, treated medically (n = 52); (3) patients without viability, revascularized (n = 25); and (4) patients without viability, treated medically (n = 61). Of these patients, 45 (23%) patients suffered 57 cardiac events: 18 cardiac deaths (9%), 7 MIs, 12 unstable angina, 9 heart failures, and 11 new revascularization procedures. Patients with viability, revascularized, experienced a slightly lower event rate (22%) compared with patients with viability, treated medically, patients without viability, treated medically and patients without viability, revascularized (29%, 31%, and 36%, respectively; p = not significant [NS]). The frequency of events was then evaluated in those 108 patients with an ejection fraction < or =33%, in whom 14 cardiac deaths occurred: the incidence of cardiac death was slightly lower in patients with viability, revascularized (3/37, 8%) than in the patients with viability, treated medically (4/26, 15%), patients without viability, revascularized (2/11, 18%), or patients without viability, treated medically (5/34, 15%) (p = NS). Nonfatal cardiac events were significantly fewer (p <0.05) in patients with viability, revascularized (8%) and in patients without viability, treated medically (6%) than in patients with viability, treated medically and patients without viability, revascularized (27%). In infarcted patients with severe left ventricular dysfunction, the presence of viable myocardium, if left unrevascularized, leads to further events. On the contrary, in the absence of myocardial viability, revascularization could lead to a worse prognosis than medical therapy.

[El Nino in Borbon, Ecuador]

The "global" climatic phenomenon of El Niño is described in its "local" expressions and dramatic health implications through the daily chronicle of what happens in an area of the Pacific Amazonia in Ecuador. The report is also an example of how health promoters living with the communities substantially contribute to the comprehensive surveillance of the life, and not only of the health, of micro-populations, which is the characteristics of community epidemiology.

Comparison of left ventricular function and volumes during transesophageal atrial pacing combined with two-dimensional echocardiography in patients with syndrome X, atherosclerotic coronary artery disease, and normal subjects

Nine patients with syndrome X were compared with 2 groups of patients known to have coronary artery disease (CAD) (8 patients who developed regional wall motion abnormalities [group ECHO+] and 6 patients who showed only ST depression at echo-pacing [group ECG+]) and with 6 healthy volunteer control subjects. Left ventricular function at rest was normal in all patients. End-diastolic and end-systolic volumes (ml/m2) and ejection fraction were calculated at baseline and at peak of echo-pacing using a Simpson's biplane method. No regional wall motion abnormalities were observed during the echo-pacing in patients with syndrome X or in the volunteers. End-diastolic volume decreased in patients with syndrome X, in the volunteers (from 47 +/- 11 to 30 +/- 12 and from 72 +/- 7 to 38 +/- 6, respectively, p <0.01 for both), and in ECG+ patients (from 48 +/- 10 to 33 +/- 6, p <0.05), whereas it did not change in ECHO+ patients. End-systolic volume decreased in patients with syndrome X and in the volunteers (from 17 +/- 5 to 11 +/- 4 and from 28 +/- 6 to 16 +/- 4, respectively, p <0.01 for both), whereas it did not change or else slightly increased in patients with CAD (from 18 +/- 10 to 16 +/- 5 for ECG+ patients and from 19 +/- 5 to 24 +/- 9 for ECHO+ patients, p = NS for both), regardless of whether regional wall motion abnormalities appeared. Ejection fraction decreased in ECG+ and ECHO+ patients (from 64 +/- 12 to 52 +/- 11 and from 62 +/- 9 to 44 +/- 13, respectively, p <0.01 for both), whereas it did not change in patients with syndrome X and in the volunteers (from 64 +/- 8 to 61 +/- 8 and from 61 +/- 7 to 58 +/- 7, respectively, p = NS for both). During echo-pacing in syndrome X patients no regional wall motion was detected. Left ventricular volumes and ejection fraction showed the same patterns of variation in these patients as they did in the healthy control subjects, in contrast with those patients with CAD, whether or not regional wall motion abnormalities appeared in the latter.

Macrofilaricidal effects of chloroquine on adult Onchocerca volvulus by local infiltration of palpable onchocercal nodules

The macrofilaricidal effects of local infiltration of high concentrations of chloroquine into the capsule of onchocercal nodules on adult worms of Onchocerca volvulus was determined. Six weeks post infiltration, histological examination of single nodules showed all adult worms to be dead. With nodule conglomerates, there was localized action of chloroquine only on the adult worms in the infiltrated nodule, with no diffusion of the drug to adjacent nodules. Chloroquine infiltration of young, recently formed nodules to reduce the adult worm load of infected individuals may be an alternative method to costly nodulectomy.

Successful control of onchocerciasis with community-based ivermectin distribution in the Rio Santiago focus in Ecuador

Onchocerciasis is a major blinding disease in equatorial Africa and Central and South America. Ivermectin is a safe and effective drug in the treatment of this disease and now forms the basis of disease control in most endemic areas. We report the findings of long-term control of this infection in the Río Santiago focus in Ecuador, between January 1990 and December 1996, using a strategy of giving ivermectin treatments biannually in hyperendemic communities and annually in meso- and hypoendemic communities. Ivermectin was administered by local health workers from each community. A high level of compliance to ivermectin was achieved, with 81.9% to 98.0% of those eligible receiving the drug at each treatment instance. The impact of ivermectin therapy was monitored using a cohort of 120 randomly selected infected individuals from 8 hyperendemic communities. The geometric mean microfilarial density of this group declined from 19.3 to 0 mf/mg over the 84-month observation period. Ivermectin had a significant impact on anterior segment ocular disease, acute onchodermatitis and sowda. The rate of infection of blackflies declined from 1.1% in 1989-0.08% in 1996, which is below the vectorial capacity of the Simulium vector and, as no new nodules were detected after 1994 and no children under 5 became infected over the observation period, it is likely that the transmission of this infection was interrupted in the study area.

Opposite effects of the remodeling of infarcted and non-infarcted myocardium on left ventricular function early after infarction in humans. An echocardiographic study in patients examined before and after myocardial infarction

OBJECTIVE

The purpose of this study was to evaluate infarction-related changes in the infarcted and the non-infarcted myocardium using a baseline assessment of ventricular function obtained prior to the infarction.

BACKGROUND

Experimental studies have shown that both infarcted and non-infarcted myocardium contribute to the process of left ventricular dilatation soon after the infarction, but no data exist on the effect that the infarct has on the pre-infarct ventricular morphology in humans.

METHODS AND RESULTS

10 patients, out of 721 admitted to our coronary care unit with a first acute myocardial infarction over a 3-year period, had had an echocardiographic examination performed before (354 +/- 407 days) and after (10 +/- 9 days) the infarction which were adequate for quantitative evaluation. Ventricular volume (Simpson) and regional wall motion (Centerline method) were evaluated by biplane apical sections and the endocardial length of the infarct and the non-infarct segments, imaged in a cross-sectional view at the papillary muscle level, were measured. After the infarction end-diastolic and end-systolic ventricular volume increased (P = 0.0003 and P < 0.0001, respectively); diastolic and systolic infarct segment length increased (P = 0.011 and P = 0.0008, respectively), while non-infarct segment had only diastolic lengthening (P = 0.019), without systolic changes. The ejection fraction decreased after the infarction (P < 0.0001), in inverse relation to infarct size and in direct relation to diastolic non-infarct segment lengthening. In the five patients in whom there was a significant diastolic lengthening of non-infarct segment (larger than mean +/- 2 S.D. of the interobserver variability) the decrease in ejection fraction was less than in the patients without significant lengthening of this segment (P = 0.017), despite a similar echocardiographic infarct size index.

CONCLUSION

Ventricular enlargement early after myocardial infarction is due to both infarct expansion and lengthening of non-infarct segment. However, while systolic stretching of the infarct segment is a deleterious process that accounts for the increase in end-systolic volume, diastolic non-infarct segment lengthening is the expression of a functional compensatory mechanism that counteracts the reduction of the ventricular pump function secondary to the infarction.

Primary cardiac leiomyosarcoma: seven-year survival with combined surgical and adjuvant therapy

Primary cardiac sarcomas constitute a rare entity that have been uniformly associated with poor long-term survival. A case of left atrial leiomyosarcoma involving the interatrial septum and the right atrial free wall and presenting with syncope and atrial fibrillation, is described. Two extensive surgical excisions followed by adjuvant radiation and chemotherapy improved survival with a good quality of life. This approach of combined surgical, medical and radiation therapy may offer better longterm outcome, since our patient is the longest survivor thus far reported.

Onchocerciasis and reproductive health in Ecuador

A retrospective study was performed comparing the number of spontaneous abortions in a hyperendemic area for onchocerciasis in Ecuador before and after invermectin treatment with that of a comparable non-endemic area. The frequency of spontaneous abortions was associated with a change in the community microfilarial load, suggesting that there may be a relationship between spontaneous abortions and infection with Onchocerca volvulus. In the endemic area, a significantly greater rate of spontaneous abortions was seen in the period before ivermectin distribution compared to that after the start of ivermectin treatments every 6 months. In the non-endemic area, no change in the rate of spontaneous abortions was seen over the same time period. In addition to the well-documented improvements in skin and ocular disease, ivermectin may also improve the reproductive health of endemic populations.

Onchocerciasis in Ecuador: prevalence of infection on the Ecuador-Colombia border in the Province of Esmeraldas

The prevalence of onchocerciasis infection was determined in communities on 7 rivers located in the northern area of the canton San Lorenzo, province of Esmeraldas. Diagnosis of the infection was obtained by skin biopsies and recombinant-antigen based-serology. No evidence of infection was detected in 9 communities studied along the Rio Mataje, which forms the frontier between Ecuador and Colombia, nor in 10 adjacent communities located on 5 interior rivers. Evidence for Onchocerca volvulus infection was found in 4 communities on the Rio Tululvi with the following prevalence: La Boca (3.5% by biopsy and 3.9% by serology), Guayabal (9.1% by both biopsy and serology), La Ceiva (51.5% by biopsy and 53% by serology), and Salidero (4% by biopsy and 7.7% by serology). A few individuals in these communities were seropositive for O. volvulus in the absence of detectable dermal microfilariae: these might harbor very light or prepatent infections. No clinical disease attributable to onchocerciasis was found. The infected communities will be included in the ivermectin-based National Control Program for the disease, with no evidence of the infection having extended north of the Ecuadorian-colombian border.

Onchocerciasis in Ecuador: evolution of chorioretinopathy after amocarzine treatment

AIMS

To investigate the impact of the macrofilaricidal drug, amocarzine, on the evolution of chorioretinopathy in onchocerciasis.

METHODS

A prospective uncontrolled cohort study was performed using subjects infected with Onchocerca volvulus in a hyperendemic onchocerciasis focus in Esmeraldas Province in Ecuador. Study subjects were recruited into four cohorts in which ophthalmic and parasitological data were collected for 2, 3, 4, and 5 years respectively.

RESULTS

Complete ophthalmic follow up was obtained for 294 individuals in the four cohorts. The incidence of retinal pigment epithelial atrophy tended to remain constant between cohorts while that of chorioretinal scarring with a greater observation period. The incidence rate of cases with new or extending chorioretinal lesions was greater with an increasing period of follow up. An association was seen between the cumulative microfilarial loads in the skin and the development of new chorioretinal lesions (p < 0.05). No relation was noted between cumulative microfilarial loads and the progression of existing disease.

CONCLUSION

Amocarzine therapy did not prevent the natural evolution of chorioretinal disease. It was suggested that ocular microfilariae were necessary for the induction of chorioretinopathy in previously unaffected eyes and that extension of existing disease might also be related to the presence of ocular microfilariae or to other immunological mechanisms.

[Care of skin infections in patients in peritoneal dialysis]

The incidence of exit-site infections among peritoneal home-dialysis patients was quantified following for 1 year all home dialysis patients of 23 dialysis centres. The exit site conditions were observed and classified according to Twardowsky. When an infection occurred data on its treatment were collected. 393 patients were observed. The infection occurred in 40 patients (10.1%). 82.2% of patients wear a Tenckoff catheter, 3% do not protect the exit site with any kind of dressing. The strategies adopted by different centres vary for the choice of antiseptics, the suggested frequency of changes dressing and the routine use of nasal swabs. Due to the limited number of patients with infection no association was found between tunnel direction or frequency of dressing changes and infections occurrence. Discussion on controversial aspects and the definition of common guidelines for instance for frequency of dressing changes, use of antiseptics is warranted.