Physiotherapeutic Scoliosis-Specific Exercises (PSSE-Schroth) can reduce the risk for progression during early growth in curves below 25°: prospective control study

BACKGROUND

The main treatment aim in mild scoliosis is to prevent progression and if possible, to avoid bracing. Physiotherapeutic Scoliosis Specific Exercises (PSSE) are curve pattern specific exercises, based on 3D self-correction and activities of daily living training.

AIM

The objective of this study was to evaluate the efficacy of PSSE - Schroth, as an exclusive treatment, during the riskiest period of rapid growth.

DESIGN

Prospective control study.

SETTING

Outpatient treatment.

POPULATION

Adolescents with scoliosis.

METHODS

One hundred and sixty-three patients (148 girls,15 boys; mean age 12.6 years, Risser sign 1.1, thoracic (Th) Cobb angle 20.8° and lumbar/thoracolumbar (L/TL) Cobb angle 20.7°) performed PSSE - Schroth exercises in our clinic. They were asked to regularly attend supervised sessions and to follow a home-program at least 5 times per week. Our inclusion criteria were Cobb angle 15°-25°, Risser 0-2 and angle trunk rotation (ATR) >5°, measured by scoliometer. The outcome parameters were the Cobb angle before and after the intervention (improvement or progression were defined as angle difference more than 5°) and the number of patients that finally needed a brace. Average follow-up time was 29.4 months. Control group was consisted of 58 patients (54 girls, 4 boys; mean age 13.1 years, Risser sign 0-2, Th Cobb 19.4°, L/TL Cobb 19.2°), that were retrospectively analyzed and performed general or no exercises. Compliance was self-reported. Statistical analysis was performed by paired t-test.

RESULTS

For PSSE - Schroth group, 103 patients (63.2%) remained stable, 39 (23.9%) improved and 21 (12.9%) worsened. The success rate (87.1%) was significantly higher compared to Control group (P=0.002), where 15 subjects (25.9%) were stable and 43 (74.1%) worsened. Similarly, 16 patients (9.8%) from PSSE - Schroth group finally needed a brace, while 39 (67.2%) from control group (P=0.01).

CONCLUSIONS

PSSE - Schroth reduced the risk of progression in Adolescent Idiopathic Scoliosis (AIS) patients, during early growth. Our results are in accordance with the recently published literature, showing the effectiveness of PSSE and their superiority compared to general exercises or natural history.

CLINICAL REHABILITATION IMPACT

Scoliosis specific exercises can be the first step of scoliosis treatment in mild curves, to avoid progression and bracing.

Effects of Manual Therapy Plus Pain Neuroscience Education with Integrated Motivational Interviewing in Individuals with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial Study

Background and Objectives: Chronic non-specific low back pain (CNLBP) persists beyond 12 weeks. Manual therapy recommended for CNLBP demonstrates short-term efficacy. Pain Neuroscience Education (PNE) teaches patients to modify pain perception through explanations, metaphors, and examples, targeting brain re-education. Motivational Interviewing (MI) enhances motivation for behavioral change, steering patients away from ambivalence and uncertainty. These approaches collectively address the multifaceted nature of CNLBP for effective management. The aim of this study was to investigate a manual therapy intervention combined with PNE with MI on pain, pressure pain threshold (PPT), disability, kinesiophobia, catastrophizing, and low back functional ability in individuals experiencing CNLBP. Materials and Methods: Sixty adults with CNLBP were randomly divided into three equal groups (each n = 20). The first group received manual therapy and PNE with integrated MI (combined therapy group), the second group underwent only manual therapy (manual therapy group), and the third group followed a general exercise program at home (control group). Pain in the last 24 h was assessed using the Numeric Pain Rating Scale (NPRS), functional ability with the Roland-Morris Disability Questionnaire (RMDQ), PPT in the lumbar region through pressure algometry, kinesiophobia with the Tampa Scale for Kinesiophobia (TSK), catastrophizing with the Pain Catastrophizing Scale (PCS), and performance using the Back Performance Scale (BPS) at baseline, in the fourth week, and six months post-intervention. Results: Statistically significant differences between the intervention groups and the control group were found in both the fourth-week measurement and the six-month follow-up, as evident in the NPRS and RMDQ scores, as well as in the total values of tested PPTs (p < 0.05). Differences were also observed between the two intervention groups, with a statistically greater improvement in the combined therapy group at both time points (fourth week and six-month follow-up) (p < 0.05). Regarding the TSK and PCS scores in the fourth week, statistically significant differences were observed between the two intervention groups compared to the control group, as well as between the two intervention groups (p < 0.05). However, in the six-month follow-up, statistically significant differences were found only between the combined therapy group and the other two groups, with the combined therapy group showing significant improvements (p < 0.05). In relation to BPS, both intervention groups exhibited statistically significant differences compared to the control group in the fourth week, without any significant differences between the two intervention groups. However, in the six-month follow-up, significant differences were noted between the combined therapy group and the other two groups (p < 0.05), with combined therapy demonstrating greater improvement. Conclusions: The addition of PNE with integrated MI enhanced the positive effects of a manual therapy intervention in all outcome measures. The combination of manual therapy plus PNE with integrated MI appeared to provide greater improvements compared to the isolated application of manual therapy, and these improvements also lasted longer. These short- and long-term positive effects are likely attributed to the combination of PNE with integrated MI, which contributed to increasing the effectiveness of the treatment. Further studies are required to investigate the optimum dosage of manual therapy and PNE with integrated MI in individuals with CNLBP.

Diagnostic Criteria and Measurement Techniques of Sarcopenia: A Critical Evaluation of the Up-to-Date Evidence

Sarcopenia, a geriatric syndrome characterized by progressive skeletal muscle mass and function decline, poses a significant health risk among the elderly, contributing to frailty, falls, hospitalization, loss of independence and mortality. The prevalence of sarcopenia varies significantly based on various factors, such as living status, demographics, measurement techniques and diagnostic criteria. Although the overall prevalence is reported at 10% in individuals aged 60 and above, disparities exist across settings, with higher rates in nursing homes and hospitals. Additionally, the differences in prevalence between Asian and non-Asian countries highlight the impact of cultural and ethnic factors, and variations in diagnostic criteria, cut-off values and assessment methods contribute to the observed heterogeneity in reported rates. This review outlines diverse diagnostic criteria and several measurement techniques supporting decision making in clinical practice. Moreover, it facilitates the selection of appropriate tools to assess sarcopenia, emphasizing its multifactorial nature. Various scientific groups, including the European Working Group of Sarcopenia in Older People (EWGSOP), the International Working Group on Sarcopenia (IWGS), the Asian Working Group on Sarcopenia (AWGS), the American Foundation for the National Institutes of Health (FNIH) and the Sarcopenia Definition and Outcomes Consortium (SDOC), have published consensus papers outlining diverse definitions of sarcopenia. The choice of diagnostic criteria should be aligned with the specific objectives of the study or clinical practice, considering the characteristics of the study population and available resources.

Childhood Mediterranean Diet Adherence Is Associated with Lower Prevalence of Childhood Obesity, Specific Sociodemographic, and Lifestyle Factors: A Cross-Sectional Study in Pre-School Children

BACKGROUND

The Mediterranean diet (MD) has been related with a decreased probability of overweight/obesity as well as central obesity at all stages of the human life, decreasing the risk of diverse disease states and improving quality of life. Over the last few years, the prevalence of childhood overweight/obesity and especially abdominal obesity has highly increased worldwide, being associated with a higher likelihood of overweight/obesity as well as central obesity at the next stages of the life during adulthood. The purpose of the present study was to explore the relationship of MD compliance with sociodemographic, anthropometry and lifestyle features in pre-school children aged 2-5 years old.

METHODS

This is a cross-sectional study, which includes 5188 pre-school children from diverse regions of Greece. Relevant questionnaires were applied to evaluate the sociodemographic features of the enrolled children. Anthropometric parameters were measured by relevant techniques. Qualified questionnaires were utilized for assessing several lifestyle factors such as physical activity, quality of life, breastfeeding practices, MD adherence, as well as the prevalence of childhood asthma and diabetes mellitus type I.

RESULTS

Of the enrolled children, 41.7% showed low MD compliance and 36.4% of them indicated moderated compliance, while only 21.9% of them showed a high MD adherence. Overweight/obesity was noted in 24.2% of the assigned children, while abdominal obesity was noticed in 18.2% of them. Higher MD compliance was related with an elevated prevalence of sex (boys, p = 0.0005), Greek nationality (p = 0.0088), rural type of residence (p = 0.0099), childhood overweight/obesity (p < 0.0001) and abdominal obesity (p < 0.0001), lower childbirth weight (p < 0.0001), increased physical activity (p = 0.0041), improved quality of life (p = 0.0008), exclusive breastfeeding (p < 0.0001), childhood asthma (p = 0.0001) and diabetes mellitus type 1 (p = 0.0002).

CONCLUSIONS

A higher MD adherence is associated with specific sociodemographic, better anthropometric, and beneficial lifestyle factors in pre-school children. However, MD compliance remains low or moderate in the vast majority of children aged 2-5 years old. Thus, future public strategies and policies should be performed to inform parents of the potential beneficial effects of MD against obesity and related chronic diseases at the next stage of their children's lives.

Association of Gestational Hypertension with Sociodemographic and Anthropometric Factors, Perinatal Outcomes, Breastfeeding Practices, and Mediterranean Diet Adherence: A Cross-Sectional Study

Background and Objectives: Gestational hypertension has been associated with several pregnancy short-term and long-term complications, affecting both the mother and her infant's health. The present study aims to assess the potential association of gestational hypertension with sociodemographic and anthropometry factors, perinatal outcomes, breastfeeding habits, and Mediterranean diet (MD) compliance. Materials and Methods: This is a cross-sectional study conducted on 5271 mothers that was carried out after delivery. The anthropometry characteristics and perinatal outcomes were retrieved from the mothers' medical records. Sociodemographic characteristics, MD adherence, and breastfeeding habits were assessed via one-to-one interviews of the assigned women with qualified staff. Results: Maternal older age, being employed, family history of gestational hypertension, overweight/obesity before gestation, and abnormal gestational weight gain (GWG) independently increased the risk of developing gestational hypertension. Moreover, gestational hypertension was independently related with a greater incidence of abnormal childbirth body weight and preterm birth, not exclusively breastfeeding, and lower levels of MD adherence. Conclusions: This study highlights the importance of informing future mothers about the risk factors of gestational hypertension, underlining also that a healthy lifestyle, which simultaneously includes a healthy nutritional pattern such as MD, may decrease the risk of developing gestational hypertension and the subsequent pregnancy complications.

Short-Term Effects of Manual Therapy plus Capacitive and Resistive Electric Transfer Therapy in Individuals with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial Study

Background and Objectives: Chronic non-specific low back pain (CNSLBP) is defined as back pain that lasts longer than 12 weeks. Capacitive and resistive electric transfer (TECAR) therapy utilizes radiant energy to generate endogenous heat and is widely used for the treatment of chronic musculoskeletal pain. The aim of this study was to investigate the efficacy of manual therapy (MT) program combined with TECAR therapy in individuals with CNSLBP. Materials and Methods: Sixty adults with CNSLBP were randomly divided equally into three groups. The first group followed an MT protocol in the lumbar region (MT group), the second group followed the same MT protocol combined with TECAR therapy (MT + TECAR group) using a conventional capacitive electrode as well as a special resistive electrode bracelet, and the third group (control group) received no treatment. Both intervention programs included six treatments over two weeks. Pain in the last 24 h with the Numeric Pain Rating Scale (NPRS), functional ability with the Roland-Morris Disability Questionnaire (RMDQ), pressure pain threshold (PPT) in the lumbar region with pressure algometry, and mobility of the lumbo-pelvic region through fingertip-to-floor distance (FFD) test were evaluated before and after the intervention period with a one-month follow-up. Analysis of variance with repeated measures was applied. Results: In the NPRS score, both intervention groups showed statistically significant differences compared to the control group both during the second week and the one-month follow-up (p < 0.001). Between-group differences were also noticed between the two intervention groups in the second week (p < 0.05). Differences in the RMDQ score were detected between the intervention groups and the control group in the second week and at the one-month follow-up (p < 0.001), while differences between the two intervention groups were only detected at the one-month follow-up (p < 0.001). Regarding the PPT values, differences were found mainly between the MT + TECAR group and the control group and between the MT + TECAR group and the MT group (p < 0.05), with the MT + TECAR group in most cases showing the greatest improvement compared to the other two groups, which remained statistically significant at the one-month follow-up (p < 0.05). Finally, both intervention groups improved the mobility of the lumbo-pelvic region at both time points compared to the control group without, however, statistically significant differences between them (p > 0.05). Conclusions: The application of an MT protocol with TECAR therapy appeared more effective than conventional MT as well as compared to the control group in reducing pain and disability and improving PPT in individuals with CNSLBP. No further improvement was noted in the mobility of the lumbo-pelvic region by adding TECAR to the MT intervention.

Efficacy of percutaneous needle electrolysis versus dry needling in musculoskeletal pain: A systematic review and meta-analysis

BACKGROUND

Physical therapists use dry needling (DN) and percutaneous needle electrolysis (PNE) to treat musculoskeletal pain.

OBJECTIVE

To investigate the efficacy of PNE vs. DN in the treatment of musculoskeletal pain.

METHODS

This systematic review and meta-analysis was based on the PICOS and PRISMA protocols. The PubMed, PEDro, Cochrane Library, SCOPUS, and Google Scholar databases were searched for randomized clinical trials measuring pain intensity in various musculoskeletal syndromes using PNE and DN. Pain outcome measures were the visual analog scale or the numerical pain rating scale. Risk of bias was assessed according to Cochrane guidelines and quality of evidence was reported using the Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE). Standardized mean differences were calculated using random effects models.

RESULTS

The meta-analysis of the six included studies showed that the overall effect of PNE vs. DN for pain reduction was statistically significant at -0.74 (95% confidence interval [CI], -1.34 to -0.14) with a large effect size (SMD =-0.41; 95% CI, -0.75 to -0.08), albeit clinically insignificant in the short, medium, and long term. Risk of bias was generally low with moderate-level evidence due to the overall effect heterogeneity and the small sample.

CONCLUSIONS

Moderate-quality evidence showed that PNE is slightly more effective than DN in reducing pain. However, because the results were not clinically significant, we cannot recommend the application of PNE over DN. More high-quality studies comparing the two interventions are needed to draw firm conclusions.

Neurorehabilitation Through Synergistic Man-Machine Interfaces Promoting Dormant Neuroplasticity in Spinal Cord Injury: Protocol for a Nonrandomized Controlled Trial

Background

Spinal cord injury (SCI) constitutes a major sociomedical problem, impacting approximately 0.32-0.64 million people each year worldwide; particularly, it impacts young individuals, causing long-term, often irreversible disability. While effective rehabilitation of patients with SCI remains a significant challenge, novel neural engineering technologies have emerged to target and promote dormant neuroplasticity in the central nervous system.

Objective

This study aims to develop, pilot test, and optimize a platform based on multiple immersive man-machine interfaces offering rich feedback, including (1) visual motor imagery training under high-density electroencephalographic recording, (2) mountable robotic arms controlled with a wireless brain-computer interface (BCI), (3) a body-machine interface (BMI) consisting of wearable robotics jacket and gloves in combination with a serious game (SG) application, and (4) an augmented reality module. The platform will be used to validate a self-paced neurorehabilitation intervention and to study cortical activity in chronic complete and incomplete SCI at the cervical spine.

Methods

A 3-phase pilot study (clinical trial) was designed to evaluate the NeuroSuitUp platform, including patients with chronic cervical SCI with complete and incomplete injury aged over 14 years and age-/sex-matched healthy participants. Outcome measures include BCI control and performance in the BMI-SG module, as well as improvement of functional independence, while also monitoring neuropsychological parameters such as kinesthetic imagery, motivation, self-esteem, depression and anxiety, mental effort, discomfort, and perception of robotics. Participant enrollment into the main clinical trial is estimated to begin in January 2023 and end by December 2023.

Results

A preliminary analysis of collected data during pilot testing of BMI-SG by healthy participants showed that the platform was easy to use, caused no discomfort, and the robotics were perceived positively by the participants. Analysis of results from the main clinical trial will begin as recruitment progresses and findings from the complete analysis of results are expected in early 2024.

Conclusions

Chronic SCI is characterized by irreversible disability impacting functional independence. NeuroSuitUp could provide a valuable complementary platform for training in immersive rehabilitation methods to promote dormant neural plasticity.

Trial Registration

ClinicalTrials.gov NCT05465486; https://clinicaltrials.gov/ct2/show/NCT05465486

International Registered Report Identifier (IRRID)

PRR1-10.2196/41152

Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial

BACKGROUND

The purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists.

PATIENTS AND METHODS

A cohort of 106 patients with DM2, 42-83 years of age, and eGFR < 60 ml/min/m² were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal-Wallis test were used for the analyses of the data.

RESULTS

Fifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m² and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018).

CONCLUSIONS

Close follow-up of DM2 patients with eGFR < 60 ml/min/m² has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.

Global avian influenza outbreaks 2010-2016: a systematic review of their distribution, avian species and virus subtype

BACKGROUND

We conducted a systematic review to investigate avian influenza outbreaks and to explore their distribution, upon avian influenza subtype, country, avian species and other relating details as no comprehensive epidemiological analysis of global avian influenza outbreaks from 2010 to 2016 exists.

METHODS

Data was collated from four databases (Scopus, Web of Science Core Correlation, PubMed and SpringerLink electronic journal) and a global electronic reporting system (ProMED mail), using PRISMA and ORION systematic approaches. One hundred seventy three avian influenza virus outbreaks were identified and included in this review, alongside 198 ProMED mail reports.

RESULTS

Our research identified that the majority of the reported outbreaks occurred in 2016 (22.2%). These outbreaks were located in China (13.6%) and referred to commercial poultry farms (56.1%). The most common subtype reported in these outbreaks was H5N1 (38.2%), while almost 82.5% of the subtypes were highly pathogenic avian influenza viruses. There were differences noticed between ProMED mail and the scientific literature screened.

CONCLUSIONS

Avian influenza virus has been proved to be able to contaminate all types of avian species, including commercial poultry farms, wild birds, backyard domestic animals, live poultry, game birds and mixed poultry. The study focused on wet markets, slaughterhouses, wild habitats, zoos and natural parks, in both developed and developing countries. The impact of avian influenza virus seems disproportionate and could potentially burden the already existing disparities in the public health domain. Therefore, a collaboration between all the involved health sectors is considered to be more than necessary.

Axial pullout strength comparison of different screw designs: fenestrated screw, dual outer diameter screw and standard pedicle screw

Background

The pullout strength of pedicle screws is influenced by many factors, including diameter of the screws, implant design, and augmentation with bone cement such as PMMA. In the present study, the pullout strength of an innovative fenestrated screw augmented with PMMA was investigated and was compared to unaugmented fenestrated, standard and dual outer diameter screw.

Methods

Twenty four thoracolumbar vertebrae (T10-L5, age 60 to 70 years) from three cadavers were implanted with the four different pedicle screws. Twelve screws of each type were instrumented into either left or right pedicle with standard screw paired with unaugmented and dual outer diameter screw paired with augmented fenestrated screw in any given vertebra. Axial pullout testing was conducted at a rate of 5 mm/min. Force to failure (Newtons) for each pedicle screw was recorded.

Results

The augmented fenestrated screws had the highest pullout strength, which represented an average increase of 149%, 141%, and 78% in comparison to unaugmented, standard, and dual outer diameter screws, respectively. Pullout strength of unaugmented screws was comparable to that of standard screws, however it was significantly lower than dual outer diameter screws.

Conclusions

Fenestrated screws augmented with PMMA improve the fixation strength and result in significantly higher pullout strength compared to dual outer diameter, standard and unaugmented fenestrated screws. Screws with dual outer diameter provided enhanced bone-screw purchase and may be considered as an alternative technique to increase the bone-screw interface in cases where augmentation using bone cement is not feasible. Unaugmented screws can be left in the pedicle even without cement and provide similar pullout strength to standard screws.

Immunologic prognostic factors of renal allograft survival

INTRODUCTION

Successful outcome of renal transplantation depends on various factors, of which immunologic is one of the most important. Accumulated experience of a single center, with the same surgical and immunological team contributes significantly to safe conclusions. Purpose of this study was the evaluation of potential factors, in particular immunologic, that influence renal allograft survival.

PATIENTS AND METHODS

During the period 1991-2013, 20,784 surgical operations have been performed in our Department of Surgery - Transplant Unit, of which 575 were renal transplantations. We examined donor and recipient demographic factors, immunologic characteristics along with patient and graft survival.

RESULTS

Renal allograft was retrieved from living-related donor in 103 cases and in 472 from cadaveric donor. Donor age was 46.7 ± 18.5 years old and 49.9% (287) were male. Recipient age was 48 ± 12.3 years old and 402 were male. HLA histocompatibility was carefully matched resulting in 85.5% renal transplants with 2-4 HLA mismatches and 93.8% renal transplants with at least one HLA-DR. Renal graft survival the first, fifth and tenth year was 89%, 76%, and 67% and patient survival was respectively 95%, 89% and 83%. Statistical analysis revealed that only donor age influenced renal graft survival (P < .05). HLA mismatches were not correlated with graft survival (log rank P = .495), but identification of panel reactive antibodies (PRA) class I and class II post transplantation had a statistically significant impact on long term renal graft survival (log rank P < .001 and P = .021, accordingly).

CONCLUSIONS

Analysis of potential prognostic factor showed that only donor age was correlated with allograft survival. Development of PRA following renal transplantation influenced long term graft survival. Good HLA matching with at least one HLA DR resulted in excellent graft and patient survival.

Mild depression versus C-reactive protein as a predictor of cardiovascular death: a three year follow-up of patients with stable coronary artery disease

OBJECTIVE

Depression is common in patients with coronary artery disease (CAD) and is associated with higher risk of cardiovascular adverse events. We aimed to explore the prognostic role of mild depression on cardiovascular mortality and compare its prognostic value with C-reactive protein (CRP) levels in patients with stable CAD.

RESEARCH DESIGN AND METHODS

We initially recruited 523 consecutive patients with stable CAD. Glucose, lipids and CRP levels were measured and an echocardiographic study was performed. In addition, depressive symptomatology was assessed with the Zung Depression Rating Scale (ZDRS, range 20-80). Patients on antidepressant treatment or with ZDRS score ≥60 were excluded. Patients were followed up at 6 month intervals (median 33 months, interquartile range 24-40 months) by telephone interview.

RESULTS

Follow-up data were obtained from 485 patients (92.7%). Nineteen patients with baseline CRP levels >10 mg/L and eight with non-cardiovascular death were excluded from analysis. Of the remaining 458 patients 113 (24.7%) presented cardiac events. Of them 21 died (4.6%), 42 developed acute coronary syndrome (9.2%), 27 (5.9%) had a revascularization procedure due clinical deterioration, two had a stroke (0.44%) and 21 (4.6%) an arrhythmic event. Multivariate Cox regression analysis showed that ZDRS score was independent predictor of cardiovascular death (hazard ratio [HR]: 1.104 with 95% confidence interval [CI]: 1.039-1.172, p = 0.001) after adjustment for conventional risk factors and CRP. The Wald test statistic of CRP was 2.59, whereas the Wald test statistic of ZDRS score was 3.23, indicating better predictability of ZDRS score. ZDRS score was also independent predictor of both cardiovascular death and arrhythmic event (HR: 1.102 with 95% CI: 1.051-1.156, p < 0.001) after adjustment for conventional risk factors and CRP levels. The main limitations of our study were the evaluation of depression at one point in time and the assessment of inflammatory burden by measuring only CRP levels.

CONCLUSIONS

Mild depression is associated with increased cardiovascular mortality and is a better predictor than CRP levels in patients with stable CAD.

Oxalate nephropathy in a diabetic patient after gastric by-pass

We report a case of 48-year-old woman with history of diabetes and hypertension, who presented with acute to chronic kidney injury. Sixteen months before presentation, she had undergone Roux-en-Y gastric by-pass (RYGB) for morbid obesity. Kidney biopsy showed lesions consistent with oxalate nephropathy and deposition of calcium oxalate crystals. An extensive workshop excluded other causes of kidney injury. The patient subsequently required dialysis with no improvement of renal function on follow-up. The mechanism by which patients develop hyperoxaluria after RYGB remains obscure; it is suggested that RYGB provokes fat malabsorption, which results in increased load of free fatty acid in the intestine. Thus, calcium binds to free fatty acids provoking reduced synthesis of calcium oxalate. Consequently, increased quantity of oxalate remains free and is absorbed in the intestine causing hyperoxaluria. Similar to our case, oxalate nephropathy after RYGB is seen in patients with diabetes, hypertension and chronic kidney injury. Treatment includes low-fat, low-oxalate diet along with administration of calcium supplements. Unfortunately, prognosis is rather poor with the majority of patients eventually requiring permanent dialysis. Therefore, patients with history of chronic kidney disease undergoing RYGB should be closely monitored, particularly those with long standing history of diabetes and hypertension.

Prospective monitoring of BK virus replication in renal transplant recipients

BACKGROUND

BK virus-associated nephropathy (BKVAN) can be diagnosed only with renal graft biopsy. Definitive diagnosis of BKVAN requires demonstration of BK virus (BKV) replication in renal allograft tissues. Non-invasive analysis of urine and blood is considered essential in screening renal transplant recipients.

PATIENTS AND METHODS

This study evaluated prospectively the replication of BKV in plasma and urine with qualitative and quantitative real-time polymerase chain reaction in 32 de novo (group A) and 34 chronic (group B) renal transplant recipients and the long-term impact on graft function.

RESULTS

In group A, 456 samples (228 plasma, 228 urine) were examined and BKV was detected in 31 (31/228, 14%) samples of plasma and 57 (57/228, 25%) samples of urine in 20 (20/32, 62.5%) and 23 (23/32, 72%) recipients, respectively. Incidence of viremia and viruria increased during the first 6 months presenting a peak the third postoperative month (viremia: 28% and viruria: 31%). Immune suppressive treatment with tacrolimus showed significant relation with viremia. Renal graft function in de novo renal transplant recipients remained stable throughout the follow-up period without influence of BKV replication. In group B, incidence of viremia and viruria were 3% (1/34) and 9% (3/34) correspondingly, indicating that after the first post-transplant year the risk of BKV re-activation is diminished.

CONCLUSION

The highest incidence of BK viremia and viruria is observed the third post-transplantation month, confirming previously published studies in Europe and the United States, and long-term follow up shows that BKV replication decreases significantly after the third post-transplant month and even transient viremia or viruria does not have an impact on renal function.

Heparin-induced thrombocytopenia type II: a serious hazard in preemptive renal transplantation: a case report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.

Hypercalcemia Due to Resistant Hyperparathyroidism in Renal Transplant Patients Treated With the Calcimimetic Agent Cinacalcet

INTRODUCTION AND AIMS

Calcimimetic agents increase the sensitivity of calcium-sensing receptors of parathyroid glands and suppress both serum calcium levels and parathyroid hormone (PTH). The use of these drugs in patients with a functioning graft suffering from resistant hyperparathyroidism and hypercalcemia is still under investigation. We report seven patients who were treated with the calcimimetic agent cinacalcet.

METHODS

The four male and three female patients of 38 to 72 years of age received a renal transplant from 4 to 35 months before cinacalcet treatment. Serum creatinine was 1.2 to 1.8 mg/dL (estimated glomerular filtration rate between 40 and 75 mL/min). Immunosuppressive treatment consisted of interleukin-2 antibody induction therapy, calcineurin inhibitors (cyclosporine or tacrolimus), prednisolone, and mycophenolate mofetil. Mild to severe hyperparathyroidism resistant to vitamin D analog treatment (intact parathyroid hormone molecule [iPTH] 174 to 519 pg/mL) was accompanied by severe hypercalcemia (Ca >11 mg%). To date the patients have completed 3 to 18 months of therapy. Cinacalcet 30 mg/d was initially administered.

RESULTS

This treatment resulted in a rapid decrease in total serum calcium (8.6 to 9.2 mg/dL) while PTH showed a milder, progressive decrease. Having controlled calcium levels, 1alpha OH vitamin D (0.25 microg/d per os) was added to the treatment, which resulted in a further decline of iPTH without producing an increase in serum calcium concentrations (median initial iPTH value 401 pg/mL, median value after treatment 176 pg/mL). Therapy was well tolerated without hypocalcemic events.

CONCLUSION

Cinacalcet offered a better holistic treatment approach to such patients.

Treatment of severe hypercalcemia due to refractory hyperparathyroidism in renal transplant patients with the calcimimetic agent cinacalcet

Calcimimetic agents increase the sensitivity of calcium sensing receptors of parathyroid glands and suppress both serum calcium levels and parathyroid hormone. There are still limited data on the treatment of renal transplant patients with severe hypercalcemia and hyperparathyroidism with calcimimetics (cinacalcet). We describe two such renal transplant patients with chronic kidney disease Stage 3 who presented with persistent hypercalcemia (serum calcium 11.5-12 mg/dl) and refractory hyperparathyroidism (iPTH 194-547 pg/ml). Control of hypercalcemia with cinacalcet (serum calcium <10 mg/dl) resulted also in an improvement of hyperparathyroidism, but with a slower rate than that of the lowering of serum calcium. Addition of a vitamin D analog together with the calcimimetic agent resulted in faster control of the resistant hyperparathyroidism in both patients (iPTH <145 pg/ml) with clinical improvement and without any side effect. It seems that this new agent will improve our clinical approach of renal bone disease permitting a more integrated and successful treatment of hyperparathyroidism and its consequences on patients with chronic kidney disease.

Pedicle dimensions of the thoracic and lumbar vertebrae in the Greek population

The aim of this study is to understand the magnitude of the pedicle's diameters for the use of pedicle screw fixation in spinal instrumentation. Pedicle dimensions from T1 to L5 were measured in 16 whole human cadaver spines (eight women and eight men). The mean age at the time of death was 67.2 (range: 59-84 years). The external transverse, the external sagittal, and the internal transverse diameter pedicle widths were measured with electronic calipers both on the right and left pedicles. The widest external transverse diameter was at the L5 level with a mean of 13.61 mm (range: 10.29-16.20 mm). The narrowest external transverse pedicle diameter was at the T5 level with a mean of 5.09 mm (range: 4.10-6.88 mm). The widest external sagittal pedicle diameter was at the T11 level with a mean of 17.02 mm (range: 14.84-19.57 mm), while the narrowest one was at T1 level with a mean of 8.90 mm (range: 7.18-11.37 mm). The maximum internal transverse pedicle diameter was at the L5 level with a mean 8.95 mm (range: 7.10-11.21 mm), while the minimum was at the T5 level with a mean 3.90 mm (range: 3.10-4.82 mm). Statistical significant greater pedicle dimensions were found in males at multiple levels. Pedicle dimensions at the levels from T3 to T8 need preoperative evaluation with computed tomography before the insertion of pedicle screws with diameter more than 5 mm. Pedicles at T12 to L5 levels may accommodate screws of 7 mm diameter.

Treatment of thrombosis of a mechanical aortic valve with fibrinolysis

We describe the case of a 57-year-old man with a mechanical aortic valve who had discontinued oral anticoagulants for a long period and presented with symptoms of severe congestive heart failure, including pulmonary oedema and hypotension. Clinical and echocardiographic examination revealed a large thrombus obstructing the prosthetic valve. Since his critical clinical condition was not improved by heparin treatment we decided to administer intravenous fibrinolysis with 100 mg rtPA. Fibrinolytic treatment was entirely successful, with complete thrombus dissolution and restoration of clinical status. Thrombosis of mechanical prosthetic valves is a particularly serious complication with a high mortality rate. Early diagnosis and treatment are of paramount importance for these patients. Although surgical intervention is the suggested treatment in many series, fibrinolytic therapy offers a good alternative with a high success rate, especially in the critically ill patient where surgery carries a high risk of mortality.

Percutaneous Harlow Wood needle biopsy of the spine: a retrospective analysis of 238 spine lesions

This retrospective study assessed the diagnostic accuracy and clinical usefulness of the Harlow Wood needle biopsy for spinal lesions. The medical records of 238 patients (138 men and 100 women) who underwent closed spine biopsy from 1987 through 1997 were reviewed. Patient age ranged from 21 to 83 years. Lesions involved the thoracic vertebrae in 127 patients, the lumbar vertebrae in 99 patients, and the sacrum in 12 patients. Cultures of the biopsy specimens were examined histopathologically and cytologically. One hundred twenty-four patients were diagnosed with a spinal infection, and 68 patients were diagnosed with a tumor. In the remaining 46 patients, the biopsy specimens were negative for infection or neoplasia in 20 patients and not diagnostic in 26 (10.9%) patients. There were no major complications. The Harlow Wood needle biopsy is a simple, repeatable procedure with satisfactory diagnostic accuracy (89.1%) and can be performed on an outpatient basis.

Transplantation of pediatric kidneys to adult recipients: An analysis of 13 cases

INTRODUCTION

The shortage of cadaveric donors for kidney transplantation has prompted many centers to expand the criteria used for donor selection to increase the organ supply. The use of cadaveric pediatric kidneys has been suggested as a means to overcome the shortage. However, some studies indicate that kidneys from pediatric donors show inferior results to those from adult donors. In this retrospective study we examined the outcome of kidney transplantation using cadaveric pediatric donors.

MATERIALS AND METHODS

From October 1990 to May 2002, 13 adult patients received pediatric renal transplants including two that were transplanted en bloc. The patients were divided into two groups based upon donor age: group I donors were 18 months to 6 years old; the seven recipients were of mean age 47.3 years. Group II donors were 7 to 15 years old; the six recipients were of mean age 43.6 years old. Cyclosporine-based immunosuppressive regimens were used in both groups.

RESULTS

The patient survival rate was 85.7% in group I and 100% in group II. The graft survival rates at the first and third posttransplant year in group I were 71.4% (5/7) and 57.1% (4/7) and in group II, 66.7% and 50%, respectively. The frequency of urinary complications in group I was 28.5% (2/7) and in group II 33.3% (2/6). There was one case of venous thrombosis in group II.

CONCLUSION

Pediatric renal grafts may be used with reasonable safety. However, surgical complications remain a significant problem especially with younger pediatric grafts.

Severe acute renal failure in a 19-year-old woman following laparoscopic cholecystectomy

A case of severe acute renal failure in a young female patient necessitating renal replacement therapy after laparoscopic cholecystectomy is described. The histology of the renal lesion assigned to the effects of laparoscopic surgery is relevant for the pathogenesis of renal complications after such procedures. This explains part of the pathogenesis of the ischemic lesions in kidney structure that increased intra-abdominal pressure can provoke. Emphasis is given on the prevention of such side effects.

Morphometric characteristics of the thoracic and lumbar pedicles in the Greek population

OBJECTIVES

To measure the dimensions of the pedicles of T1 to L5 in the Greek population.

METHODS

A total of 12 whole human cadaver spines were evaluated regarding pedicle dimensions (5 women and 7 men). The mean age at the time of death was 69,6 (range 62 to 84 years). The transverse and sagittal out side pedicle isthmus widths, the internal transverse diameter and cortex width were measured with electronic calipers both on the right and left pedicles. The data collected were statistically analyzed with the t-test.

RESULTS

The widest transverse diameter was at the L5 level with a mean of 11,3mm (range 7,55-15,46mm). The narrowest transverse diameter was at the T5 level with a mean of 5,37mm (range 4,10-6,88mm). The widest sagittal diameter was at the T11 level with a mean of 17,23mm (range 14,84-19,57mm), while the narrowest one was at T1 level with a mean of 9,1mm (range 7,18-11,37mm). The maximum internal transverse diameter was at the L4 level with a mean of 8,26 mm (range 7,10-9,23mm) while the minimum was at the T5 level with a mean of 3,9mm (range 3,14-4,78mm). The maximum cortex width was at the L5 level with a mean of 2,55mm (range 2,15-3,02mm) and the minimum at the T5 level with a mean of 1,30mm (range 0,40-2,10mm).

CONCLUSIONS

From the statistic analysis of the above data it was found that regarding the internal diameter there was statistically significant difference between males and females especially at T3, T7, T8 and L3 levels (P<0,05), and almost in all levels regarding the cortex width. There was also statistically significant difference between right and left pedicles regarding the transverse and the sagittal widths (P<0,05). The narrowest pedicle was at the T5 level and the widest was at the L5.

Comparative haemodynamic responses to the first dose of short- and long-acting ACE inhibitors in patients with congestive heart failure

BACKGROUND

Angiotensin Converting Enzyme inhibitors (ACEi's) confer significant mortality and morbidity benefits in all functional grades of chronic heart failure (CHF). However, physicians' concerns regarding the possible occurrence of first-dose hypotension appear to be a contributing factor to their under-utilisation in both hospital and primary care settings. We investigated whether long-acting and short-acting ACEi's differ in their haemodynamic responses to the first-dose in patients with CHF.

METHOD

This was a multicentre, randomised, open, two-parallel-group study of captopril 6.25 mg and perindopril 2 mg. 240 patients with CHF, age 68.9 +/- 8.9 years, of whom 66% were male, NYHA II-IV, with average blood pressure baseline values of 132.2 +/- 16.2/78.5 +/- 10.5 mmHg for systolic and diastolic blood pressure, and left ventricular ejection fraction (LVEF) of 31.3 +/- 7.4% received either captopril (n = 124) or perindopril (n = 116). Blood pressure was continuously monitored during the 8 h following drug intake. Minimum levels and maximum decreases in systolic, diastolic and mean arterial pressures were measured, along with the incidence of hypotensive episodes defined as mean blood pressure (MBP) fall > 20 mmHg, whether symptomatic or not. Subgroups of patients distributed according to age, baseline blood pressure (BP) and LVEF were subsequently analysed.

RESULTS

Overall, a statistically significant treatment effect in favour of perindopril was observed. First-dose hypotension was observed more frequently following captopril than perindopril administration, with lower MAP minimal levels (78.0 +/- 8.9 vs. 84.5 +/- 10.1 mmHg, p < 0.0001), greater maximum falls (17.6 +/- 8.3 vs. 12.8 +/- 7.3 mmHg, p < 0.0001) and more frequent hypotensive episodes (42% vs. 15%, p < 0.0001). The incidence of at least one symptomatic episode was also significantly higher with captopril (10 patients vs. one patient, p = 0.029). Subgroup analyses according to age (< or = 70 years or > 70 years) or LVEF (< or = 30% or > 30%) reflected the main result.

CONCLUSION

Initiation of treatment with ACE inhibitors is associated with different haemodynamic and clinical tolerances in CHF patients, regardless of their risk for hypotension, with possible clinical implications.

Correlation of bone mineral density with the histological findings of renal osteodystrophy in patients on hemodialysis

AIMS

To examine the distribution of bone mineral density (BMD) in different histological groups of renal osteodystrophy.

PATIENTS

We prospectively studied 62 patients, 41 men and 21 women, aged 57+/-11.5 years, who had been on hemodialysis for 60+/-55 months. The women had been amenorrheic for 13+/-4 years and 7 patients (11%) had a positive fracture history.

METHODS

A bone biopsy was taken after tetracycline labelling and BMD of the lumbar spine and proximal femur was measured by dual-energy X-ray absorptiometry (DEXA); serum intact parathyroid hormone (iPTH), bone Gla protein (BGP), phosphorus, calcium and alkaline phosphatase (ALP) were also determined.

RESULTS

Histologically, 40 patients showed secondary hyperparathyroidism (sHPT), 6 mixed bone disease, 14 adynamic bone disease (A) and 2 osteomalacia. BMD of the lumbar spine was decreased in 43 patients (69%) and in 9 (14.5%) it was lower than -2 Z score units. BMD of the femoral neck was low in 55 patients (89%) and in 22 (35.5%) it was lower than -2 Z scores. BMD was lower in patients with sHPT than in those with adynamic bone disease (p<0.05) in which it was close to normal. BMD in both these sites correlated inversely with the biochemical markers (serum iPTH, BGP and ALP) and the histomorphometric indices of bone turnover.

CONCLUSIONS

Osteopenia is frequent in patients on hemodialysis, especially those with biochemical and histological findings of sHPT.

Neuropathy and quality of life in diabetic continuous ambulatory peritoneal dialysis patients

Diabetes mellitus is the commonest cause of end-stage renal failure and is associated with considerable morbidity. Neuropathy is one of the most serious complications of diabetes, linked to the incidence of nephropathy and retinopathy. The prevalence of neuropathy increases with age and duration of diabetes. Peripheral sensorimotor neuropathy is the main manifestation of neurological damage in diabetes, while autonomic neuropathy, a devastating complication, is also present in a large number of patients with long-term diabetes. Clinical features of autonomic neuropathy are mainly cardiovascular disorders and abnormal visceral function. One of the most important sequelae of neuropathy is the development of the insensitive foot at risk of ulceration, deformation, Charcot neuroarthropathy, and amputation. Prevention, education, and identification of the at-risk patient are the key elements in managing these severe complications. Dialysis, and mainly peritoneal dialysis, still remains the main renal replacement therapy for end-stage renal disease (ESRD) diabetic patients. It is obvious from many studies that diabetes and its complications are major risk factors associated with poorer survival rates, increased morbidity, and decreased quality of life. Few, if any, data are available specifically evaluating quality of life in continuous ambulatory peritoneal dialysis (CAPD) diabetic patients. Fewer data are available estimating the impact of neuropathy on the quality of life of such patients. Specific studies must be carried out to further investigate quality-of-life issues and neuropathy in this vulnerable group of patients.

Regression of massive tumoral calcinosis of the ischium in a dialysis patient after treatment with reduced calcium dialysate and i.v. administration

BACKGROUND

Tumoral calcinosis, an inherited metabolic disorder, has been described with increasing frequency over the last 20 years [Drueke 1966]. It is characterized by massive calcium phosphate deposits in periarticular tissues, usually around large joints, especially the hips, knees and elbows (editorial in Lancet 1987).

PATIENT AND METHOD

We describe a 58-year-old male patient with tumoral calcinosis of the ischium and severe hyperparathyroid bone disease, successfully treated with reduced calcium dialysate and vitamin D.

CONCLUSION

We believe that in cases of tumoral calcification with histologically proven hyperparathyroid bone disease, lowering the calcium dialysate concentration together with careful administration of vitamin analogs and monitoring of serum calcium, phosphate and parathyroid hormone levels, may be the ideal therapeutic approach. Control of hyperphosphatemia would be best achieved with measures other than administration of aluminium phosphate binders if one wishes to avoid the induction of adynamic bone.

Segmental spinal correction of idiopathic scoliosis. Luque rods and Hartshill rectangle in 30 patients followed for 2-6 years

30 patients with idiopathic scoliosis were treated by posterior spinal arthrodesis using the Luque (8 patients) and Hartshill (22 patients) rodding systems with sublaminar segmental wiring. Patients were followed for 2 to 6 years. In most cases, postoperative correction exceeded safety correction limits (lateral bending film plus 10 degrees). Final correction was 55%, while derotation was not significant (average 3 degrees). No neurological deficit was noted. Postoperative bracing was not applied and there was 1 patient with broken rods (Luque trolley system without fusion) and 1 patient with broken wires in 4 segments. Allogenic blood transfusion was avoided in 19 patients by preoperative donation of autologous blood, in combination with salvage of intraoperative shed blood. We found segmental spinal wiring with either rods or rectangles to be a safe method for correction of scoliosis in experienced hands. It offered satisfactory stability and fusion rate with no need for external support.

Biochemical markers for non-invasive diagnosis of hyperparathyroid bone disease and adynamic bone in patients on haemodialysis

The diagnostic and predictive value of serum intact parathyroid hormone (iPTH) and osteocalcin (bone Gla protein, BGP), alone or in combination, have been examined in only a small number of haemodialysis patients.

METHODS

We studied prospectively 114 patients (46 women, 68 men; mean age 52 +/- 12 years) on regular haemodialysis for a mean of 55 (6-185) months. All patients underwent labelled transiliac bone biopsy, and serum levels of iPTH, BGP and alkaline phosphatase were determined.

RESULTS

Seventy-one patients (62%) showed histological findings of hyperparathyroid bone disease, 24 (21%) mixed bone disease, six (5.5%) osteomalacia and 13 (11.5%) adynamic bone. Bone aluminium deposition over more than 25% of the trabecular bone interface was found in 66 patients (58%). Serum iPTH and BGP correlated with the majority of histomorphometric indices of bone formation, mineralization and resorption (r > 0.5, P < 0.01). iPTH levels > or = 200 pg/ml and BGP > or = 50 ng/ml were found to be indicative of hyperparathyroid bone disease, whilst iPTH levels < 65 pg/ml and BGP < 20 ng/ml were indicative of adynamic bone. However, the positive predictive value of these indices was limited (less than 80%), although their negative predictive value, especially when used in combination, was good (more than 90%) and the exclusion of hyperparathyroid bone disease and adynamic bone was possible. The diagnostic and predictive value of these bone markers were improved when patients with bone aluminium deposition were excluded.

CONCLUSIONS

Diagnosis of hyperparathyroid bone disease and adynamic bone is difficult on the basis of iPTH and BGP, especially when bone aluminium deposition is prevalent. However, using these bone markers, preferably in combination, the exclusion of these lesions is feasible.

The reactivity of the contralateral artery at the time of balloon dilation during coronary angioplasty

The response of the contralateral arteries was investigated during balloon angioplasty of the left anterior descending artery. Thirty patients were studied. Coronary arteriograms were obtained at baseline, during maximal balloon inflation and at the end of the procedure. Luminal diameter was measured by a quantitative coronary arteriography analysis system. During balloon inflation the luminal diameter of the proximal segment of the right coronary artery increased by 2.4 +/- 6% (P < 0.05), and that of the left circumflex artery increased by 0.6 +/- 6% (P = ns). Both returned to near baseline values after angioplasty. In patients with increased collaterals during balloon inflation the left circumflex proximal segment increased more significantly than in patients with unchanged collaterals. The luminal diameter of the distal segment of the right coronary artery increased by 9 +/- 8% (P < 0.001) and that of the left circumflex artery by 8 +/- 11% (P < 0.01) during balloon inflation, returning to near baseline values after angioplasty. Thus, vasodilation of the contralateral arteries during balloon inflation at the time of coronary angioplasty occurs mainly in the distal segments, and appears to be related to an increase in collateral filling.

Short-term effects of atrial versus atrio-ventricular pacing on myocardial ischaemia in coronary artery disease patients

This investigation was undertaken to evaluate the effects of short-term atrial vs atrio-ventricular pacing on myocardial ischaemia. The study was in two parts. In part one, 12 coronary artery disease patients were studied to investigate the effects of the two pacing modes on angina pectoris, coronary sinus O2 saturation and lactate. The two pacing modes were each applied for 5 min at 25 beats.min-1 more than the maximum heart rate of the exercise test. Coronary sinus O2 saturation and lactate were estimated before and after pacing. In part two, 13 patients with left anterior descending coronary artery disease were studied to investigate the effects of the two pacing modes on coronary flow reserve, using a Doppler catheter in the above mentioned branch after the administration of 10 mg intracoronary papaverine. The pacing rate was 15 beats.min-1 greater than the resting heart rate. Coronary sinus lactate and O2 saturation changes were the same and angina pectoris developed at about the same time from the beginning of pacing under both modes. Coronary flow reserve was 2.1 +/- 0.7 during atrial pacing and 2.1 +/- 1.1 during atrio-ventricular pacing (ns). It is concluded that short-term atrial and atrio-ventricular pacing have the same effects on myocardial ischaemia in coronary artery disease patients.

Intravenous atenolol in elderly patients in the early phase of acute myocardial infarction

The aim of this study was to assess the hemodynamic response to intravenous atenolol in elderly patients with acute myocardial infarction. We studied 14 elderly men, aged 64-85 years, and 14 younger men, aged 29-48 years, in the early postfibrinolytic phase of acute myocardial infarction. All the patients were in Killip class I. A triple-lumen Swan-Ganz thermodilution catheter was introduced into the right heart chambers. The patients received 5 mg intravenous atenolol over 5 minutes. All hemodynamic parameters were measured before and 10 minutes after atenolol. The hemodynamic characteristics and the location and extent of acute myocardial infarction were the same in both groups before atenolol. The hemodynamic changes after atenolol administration were the same in the two groups, but the stroke volume and cardiac indexes decreased to a greater extent in the elderly (p = .01 and p = .0001, respectively). These results indicate that intravenous atenolol in the early postfibrinolytic phase of acute myocardial infarction is safe in Killip class I elderly patients, although the cardiac and stroke volume indexes decrease, and the increase in the total systemic resistance is more in older than in younger patients.

Painless myocardial ischemia in chronic hemodialysed patients: a real event?

We investigated the incidence of painless (silent) myocardial ischemia, manifested as S-T segment deviation, by Holter ECG monitoring in patients with chronic renal failure undergoing regular hemodialysis. Forty-five patients underwent Holter ECG monitoring for a continuous 48-hour period covering dialysis and the intermediate period of everyday activity at home. ECG criteria for ischemia were found in 15.5% of patients mainly during and immediately after dialysis with a simultaneous increase of R,S,R + S amplitude. There was no correlation of S-T segment deviation with the existence of cardiac dysfunction and coronary artery disease proved by hemodynamic and angiographic studies. It is concluded that hemodialysis itself seems to play an important role in the genesis of the above ECG findings, possibly by means of serum K and Mg changes.