Contribution of mitral valve leaflet length and septal wall thickness to outflow tract obstruction in patients with hypertrophic cardiomyopathy

We sought to examine whether elongation of the mitral valve leaflets in patients with hypertrophic cardiomyopathy (HCM) is synergistic to septal wall thickness (SWT) in the development of left ventricular outflow tract obstruction (LVOTO). HCM is a common genetic cardiac disease characterized by asymmetric septal hypertrophy and predisposition towards LVOTO. It has been reported that elongation of the mitral valve leaflets may be a primary phenotypic feature and contribute to LVOTO. However, the relative contribution of this finding versus SWT has not been studied. 152 patients (76 with HCM and 76 non-diseased age, race and BSA-matched controls) and 18 young, healthy volunteers were studied. SWT and the anterior mitral valve leaflet length (AMVLL) were measured using cine MRI. The combined contribution of these variables (SWT × AMVLL) was described as the Septal Anterior Leaflet Product (SALP). Peak LVOT pressure gradient was determined by Doppler interrogation and defined as “obstructive” if?≥?30 mmHg. Patients with HCM were confirmed to have increased AMVLL compared with controls and volunteers (p?<?0.01). Among HCM patients, both SWT and SALP were significantly higher in patients with LVOTO (N?=?17) versus without. SALP showed modest improvement in predictive accuracy for LVOTO (AUC?=?0.81) among the HCM population versus SWT alone (AUC?=?0.77). However, in isolated patients this variable identified patients with LVOTO despite modest SWT. Elongation of the AMVLL is a primary phenotypic feature of HCM. While incremental contributions to LVOTO appear modest at a population level, specific patients may have dominant contribution to LVOTO. The combined marker of SALP allows for maintained identification of such patients despite modest increases in SWT.     

Cardiopulmonary transplantation: experience of a lung transplant group

Cardiopulmonary transplantation (CPT) is indicated for patients eligible for heart transplantation (HT) or lung transplantation (LT) who have severe concomitant lung or heart disease. Only 2 groups perform CPT in Spain. We report our experience with 18 CPTs representing 8.2% and 5% compared with LT (220) and HT (362), respectively, from February 13, 1990 to October 15, 2002. The mean time on a waiting list was 138 days. The current number of surviving patients is 7 (39%), with a mean follow-up of 602 days (range, 3 to 4627 days). They all remain asymptomatic with normal respiratory function in 4 patients. No cardiac graft rejection has been detected. Two patients experienced sustained gastroparesis during the first year with spontaneous resolution. Death occurred within the first 3 months in 9 patients. These outcomes contrast with the early mortality associated with LT and HT in our series, namely 10.6% and 11%, respectively. The different causes of death were as follows: sepsis and multiorgan failure in 5 patients, hemorrhagic shock in 3 patients, and suture dehiscence and fungal aortic perforation in 1 patient. Late mortalities were recorded in 2 cases. Overall patient survival in our series is lower than that reported by the International Registry (IR), with an early mortality rate of 50% (30% IR). Nevertheless, our survival rate at 10 years after transplantation is 30% (26% IR). We conclude that CPT should be considered despite the greater early morbidity and mortality.     

Treatment patterns of hypertension and dyslipidaemia in hypertensive patients at higher and lower risk of cardiovascular disease in primary care in the United Kingdom

Few studies have investigated the presence of dyslipidaemia in hypertensive individuals. In addition, few data exist on the concurrent treatment of both conditions for the prevention of cardiovascular disease (CVD). This retrospective cohort study examined treatment patterns for hypertension and dyslipidaemia among hypertensive patients in UK primary care. We defined a population of patients aged > or =40 years from the UK General Practice Research Database. Hypertensive individuals with > or =3 additional cardiovascular risk factors (ARFs) were compared with a cohort comprising hypertensive patients with < or =2 ARFs. We analysed the prevalence of risk factors and the prevalence and incidence of treatment for hypertension, dyslipidaemia and for both conditions between January 1997 and December 2001. A total of 117 840 hypertensive patients were identified (23 655 with > or =3 ARFs, 94 185 with < or =2 ARFs) in 1997; in 2001, the number diagnosed as hypertensive was 133 683 (40 248 > or =3 ARFs, 93 435 < or =2 ARFs). The prevalence of antihypertensive treatment in the hypertensive patients with > or =3 ARFs increased during the study. In 2001, approximately one-third of hypertensive patients with > or =3 ARFs were not receiving antihypertensives. Among those patients who received such treatment, the majority received > or =2 separate agents in accordance with current guidelines. Treatment for concurrent hypertension and dyslipidaemia was initiated in <8% of patients with hypertension and > or =3 ARFs in each year. These findings demonstrate the under-recognition/undertreatment of cardiovascular risk factors in UK primary care among patients at risk of CVD.     

Stakeholder perspectives on intensive support teams for adults with intellectual disabilities who display behaviour that challenges in England

Background

Adults with intellectual disabilities often display behaviour that challenges that is a result of biological differences, psychological challenges, and lack of appropriate social support. Intensive Support Teams (IST) are recommended to support the care needs of this group and avoid hospitalisation. However, little attention has been paid to the perspectives of stakeholders who manage, work in, or use ISTs.

Method

Interviews and focus groups were conducted with 50 stakeholders (IST service managers and professionals, adults with intellectual disabilities, and family and paid carers) of ISTs. Services operated according to one of two service models previously identified in ISTs in England (enhanced or independent).

Results

Thematic analysis identified accessible and flexible support, individualised care, and the involvement of carers and other relevant agencies in management plans and reviews as features of good IST care highlighted by all stakeholder groups. IST managers and professionals described the key challenges of current IST provision as unclear referral criteria, limited interfaces with other local services, and perceived threats associated with funding and staff retention. Findings were similar between the two IST models.

Conclusions

ISTs are able to offer care and specialist support that is valued by families, service users and other care providers. However, they face several operational challenges that should be addressed if ISTs are to reach their potential along with community intellectual disability services in supporting adults with intellectual disabilities who display behaviour that challenges in the community.     

Does apical negative pressure prevent the apical extrusion of debris and irrigant compared with conventional irrigation? A systematic review and meta‐analysis

The aim of this study was to evaluate if apical negative pressure (ANP) irrigation prevents the apical extrusion of debris and irrigant compared with conventional needle irrigation through a systematic review and meta‐analysis. A computer search of dental literature was performed using four different databases. A combination of the terms ‘apical negative pressure’, ‘endovac’, ‘apical extrusion’, ‘extrusion’ and ‘endodontics’ was used. Studies that used extracted human teeth with a mature apex and that evaluated the apical extrusion of debris and/or irrigating solution were included. After an evaluation of the full studies according to the eligibility criteria, eight studies were critically analysed and subjected to quality assessment and risk of bias. Only four studies that evaluated extrusion of irrigant were considered as having high methodological quality and were subjected to a meta‐analysis. Studies evaluating extrusion of debris did not have sufficient methodological quality to be subjected to the meta‐analysis. The forest plot indicated that ANP irrigation prevents the risk of irrigant extrusion compared with conventional irrigation (OR 0.07 [95%CI 0.02–0.20]; P < 0.00001). This systematic review and meta‐analysis showed that ANP prevents the apical extrusion of irrigant. There is no evidence if this type of irrigation prevents the extrusion of debris.     

Novel endodontic sealers induce cell cytotoxicity and apoptosis in a dose-dependent behavior and favorable response in mice subcutaneous tissue

Clinical Oral Investigations - The objective of the present study is to evaluate the in vitro cytotoxicity and in vivo biocompatibility of two novel endodontic sealers: RealSeal XT1 and Sealapex...     

A clinical phase II study with sorafenib in patients with progressive hormone-refractory prostate cancer: a study of the CESAR Central European Society for Anticancer Drug Research-EWIV

Sorafenib is a multi-kinase inhibitor with antiangiogenic and antiproliferative activity. The activity of sorafenib in progressive hormone-refractory prostate cancer (HRPC) patients was investigated in a phase II clinical study. Progressive HRPC patients received sorafenib 400 mg bid p.o. continuously. Only patients with no prior chemotherapy, and either one-unidimensional measurable lesion according to RECIST-criteria or increasing prostate-specific antigen (PSA) values reflecting a hormone-refractory situation, were eligible for study entry. The primary study objective was the rate of progression-free survival of >/=12 weeks (PFS12). Secondary end points were overall response, overall survival, and toxicity. Fifty-seven patients with PC were enrolled. Two patients had to be withdrawn from the set of eligible patients. According to RECIST criteria, 4 patients out of 55 evaluable patients showed stable disease (SD). According to PSA-response, we saw 11 patients with SD PSA and 2 patients were responders at 12 weeks (PFS12=17/55=31%). Among the 257 adverse events, 15 were considered drug related of maximum CTC-grade 3. Twenty-four serious adverse events occurred in 14 patients (14/55=26%). Seven of them were determined to be drug related. No treatment-related death was observed. Sorafenib has antitumour activity in HRPCP when evaluated for RECIST- and PSA-based response. Further investigation as a component of combination regimens is necessary to evaluate its definite or overall clinical benefit for HRPCP.     

Ofuji's papuloerythroderma: two cases treated with azathioprine

BACKGROUND: Ofuji's papuloerythroderma is a rare disorder, characterized by a generalized pruriginous eruption, sparing the folds. It predominates in the elderly. The pathology is still unknown but associations with lymphoma have been described. Various therapeutic approaches have been tried, most often including local and general corticosteroids and PUVA. OBSERVATION: Two patients aged 71 and 84 years presented red pruriginous macular rash sparing the abdominal folds. Eosinophilia and lymphopenia were observed. Cutaneous biopsies showed dermal lymphocytic and plasmocytic infiltrates with, in one case, eosinophil and neutrophil exocytosis. Clinical, biological and morphological investigations showed no association with other diseases such as cancer or lymphoma. Azathioprine permitted clinical and biological remission in both patients but had to be interrupted because of minor side effects (infection, gastroenterologic disorders) and corticosteroids were introduced in one case. DISCUSSION: We suggest that histological aspects, such as exocytosis, may represent a link between Ofuji's papuloerythroderma and lymphoma. Azathioprine led to clinical and biological improvement in our 2 patients. Because of its adverse effects, it could be proposed as second-line therapy in patients presenting resistance or intolerance to usual treatments.