Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials.

AIM: To summarise the current evidence regarding the effectiveness of physical therapy on pain, function and range of motion in individuals with subacromial pain syndrome (SAPS). DESIGN: Systematic review. DATA SOURCES: PubMed, Web of Science, CINAHL, Cochrane, Embase, Lilacs, Ibecs and Scielo databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials (RCTs) investigating physical therapy modalities for SAPS on pain, function/disability or range of motion were included. RESULTS: 64 high-quality RCTs were included. Exercise therapy provided high evidence of being as effective as surgery intervention and better than no treatment or placebo treatment to improve pain, function and range of motion in the short, mid and long terms. The combination of mobilisation and exercises provided high evidence to decrease pain and improve function in the short term. There is limited evidence for improvements on the outcomes with the isolated application of manual therapy. High level of evidence was synthesised regarding the lack of beneficial effects of physical resources such as low-level laser, ultrasound and pulsed electromagnetic field (PEMF) on pain, function or range of motion in the treatment of SAPS. There is limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation. There is moderate evidence to no benefits with taping in the short term. Effects of diacutaneous fibrolysis and acupuncture are not well established yet. CONCLUSIONS: Exercise therapy should be the first-line treatment to improve pain, function and range of motion. The addition of mobilisations to exercises may accelerate reduction of pain in the short term. Low-level laser therapy, PEMF and taping should not be recommended.

Topographical pressure pain sensitivity maps of the shoulder region in individuals with subacromial pain syndrome.

BACKGROUND: Topographical pain maps (TPM) are useful tools to assess deep tissue sensitivity in musculoskeletal pain conditions. There is evidence suggesting bilateral sensitivity in subacromial pain syndrome (SAPS), although it is not widely accepted. No previous study has investigated TPM of the shoulder in SAPS. OBJECTIVE: To investigate whether differences for TPM of the shoulder are evident among patients with unilateral SAPS and controls. METHODS: Pressure pain thresholds (PPTs) were assessed 3 times at each point and there was a 20 s rest period between each one. The TPM were calculated using 29 pre-determined points on both shoulders in all groups by inverse distance weighted interpolation of PPT data. Multivariate Analysis of Covariance was applied to detect differences in PPTs between groups, sides, points (gender as covariate). RESULTS: The results revealed significant differences between points and genders (both, P < 0.001), but not between groups (P = 0.243) and sides (P = 0.812). Heterogeneous distribution of mechanical pain sensitivity was found in both groups as the PPTs were lower on the root spine of the scapula and the posterior border of the acromion (points 5-8, P < 0.05), glenohumeral joint (points 17-20, P < 0.01) and the anterior deltoid muscle (points 21-25, P < 0.001) compared to the average of the other sites on the shoulder. Women exhibited bilateral lower PPTs in all points than men in both groups (all, P < 0.01). CONCLUSIONS: This study revealed no differences for mechanical pain sensitivity in patients with SAPS experiencing lower levels of pain compared with matched controls, but showed heterogeneous distribution of PPTs in the shoulder.

Scapular and rotator cuff muscle activity during arm elevation: a review of normal function and alterations with shoulder impingement: [review] / Atividade dos músculos escapulares e do manguito rotator durante a elevação do braço: uma revisão da função normal e das alterações na síndrome do impacto: [revisão]

OBJECTIVE: The purpose of this manuscript is to review current knowledge of how muscle activation and force production contribute to shoulder kinematics in healthy subjects and persons with shoulder impingement. RESULTS: The middle and lower serratus anterior muscles produce scapular upward rotation, posterior tilting, and external rotation. Upper trapezius produces clavicular elevation and retraction. The middle trapezius is primarily a medial stabilizer of the scapula. The lower trapezius assists in medial stabilization and upward rotation of the scapula. The pectoralis minor is aligned to resist normal rotations of the scapula during arm elevation. The rotator cuff is critical to stabilization and prevention of excess superior translation of the humeral head, as well as production of glenohumeral external rotation during arm elevation. Alterations in activation amplitude or timing have been identified across various investigations of subjects with shoulder impingement as compared to healthy controls. These include decreased activation of the middle or lower serratus anterior and rotator cuff, delayed activation of middle and lower trapezius, and increased activation of the upper trapezius and middle deltoid in impingement subjects. In addition, subjects with a short resting length of the pectoralis minor exhibit altered scapular kinematic patterns similar to those found in persons with shoulder impingement. CONCLUSION: These normal muscle functional capabilities and alterations in patient populations should be considered when planning exercise approaches for the rehabilitation of these patients.

OBJETIVO: O objetivo deste manuscrito é revisar o conhecimento atual sobre como a ativação muscular e a produção de força contribuem para a cinemática do ombro em indivíduos saudáveis e em pessoas com síndrome do impacto. RESULTADOS: As porções média e inferior do músculo serrátil anterior produzem rotação para cima, inclinação posterior e rotação externa na escápula. O trapézio superior produz elevação e retração da clavícula. O trapézio médio é principalmente um estabilizador medial da escápula. O trapézio inferior auxilia na estabilização medial e rotação para cima da escápula. O músculo peitoral menor está alinhado para resistir às rotações normais da escápula durante a elevação do braço. O manguito rotador é crucial para a estabilização e prevenção do excesso de translação superior da cabeça do úmero, assim como para a produção de rotação externa na glenoumeral durante a elevação do braço. Foram identificadas alterações na amplitude ou no tempo de ativação em diversas investigações que compararam sujeitos portadores de síndrome do impacto com controles saudáveis. As alterações incluem ativação reduzida do músculo serrátil anterior médio ou inferior e do manguito rotador, ativação retardada do trapézio médio e inferior, assim como maior ativação do trapézio superior e do deltóide médio em sujeitos com síndrome do impacto. Além disso, sujeitos com o músculo peitoral menor com curto comprimento de repouso apresentam padrões alterados de cinemática escapular semelhantes aos encontrados em pessoas com síndrome do impacto. CONCLUSÃO: Estas capacidades musculares funcionais normais e alterações nas populações de pacientes devem ser consideradas no planejamento de programas de exercícios para a reabilitação destes pacientes.

Efeitos do alongamento ativo excêntrico dos músculos flexores do joelho na amplitude de movimento e torque / Effects of an active eccentric stretching program for the knee flexor muscles on range of motion and torque

OBJETIVO: Avaliar a amplitude de movimento (ADM) e o torque flexor e extensor do joelho após a realização de um programa de alongamento ativo excêntrico dos músculos flexores do joelho. MATERIAIS E MÉTODOS: Trinta e quatro voluntários (23 mulheres e 11 homens), 34,42±9,3 anos, realizaram um programa de alongamento ativo excêntrico dos músculos flexores do joelho na postura em pé, que consistiu de sete repetições de um minuto com 30 segundos de descanso entre as repetições. O programa de alongamento foi realizado duas vezes por semana, durante quatro semanas. A ADM de extensão e o torque flexor e extensor do joelho foram avaliados no dinamômetro isocinético pré e pós-programa de alongamento. O torque foi avaliado nos modos isométrico e isocinético concêntrico e excêntrico a 30º/s e 60º/s. RESULTADOS: Houve aumento na ADM de 53,7±13º para 30,1±16º (p=0,0001), no torque isométrico flexor de 89±32Nm para 93±33Nm (p=0,01) e extensor de 178±67Nm para 187±73Nm (p=0,006). O torque flexor concêntrico e excêntrico a 30º/s aumentou de 90±31Nm para 96±31Nm (p=0,001) e de 100±34Nm para 105±35Nm (p=0,01), respectivamente. O torque extensor concêntrico a 60º/s aumentou de 144±51Nm para 151±58Nm (p=0,02) e o excêntrico a 30º/s de 175±71Nm para 189±73Nm (p=0,01). CONCLUSÕES: O programa de alongamento proposto foi efetivo para aumentar a flexibilidade dos músculos alongados e torque dos grupos musculares agonistas (alongados) e seus antagonistas.

OBJECTIVE: To evaluate the changes in knee range of motion (ROM) and torque of knee flexor and extensor muscles after an active eccentric stretching program for the knee flexor muscles. METHODS: Thirty-four volunteers (23 women and 11 men), aged 34.42±9.3 years, performed an active eccentric stretching program for the knee flexor muscles in the standing posture, consisting of seven repetitions of one minute each, with 30 seconds of resting between them. The stretching program was performed twice a week, for four weeks. Knee extension ROM and the torque of the knee flexor and extensor muscles were evaluated using an isokinetic dynamometer before and after the stretching program. The torque was evaluated in the isometric, isokinetic concentric and eccentric modes at 30º/s and 60º/s. RESULTS: There was an increase in ROM from 53.7±13º to 30.1±16º (p=0.0001), in isometric torque of the flexors from 89±32Nm to 93±33Nm (p=0.01) and of the extensors from 178±67Nm to 187±73Nm (p=0.006). The concentric and eccentric torque of the flexors at 30º/s increased from 90±31Nm to 96±31Nm (p=0.001) and from 100±34Nm to 105±35Nm (p=0.01), respectively. The concentric torque of the extensors at 60º/s increased from 144±51Nm to 151±58Nm (p=0.02), and the eccentric torque at 30º/s increased from 175±71Nm to 189±73Nm (p=0.01). CONCLUSIONS: The stretching program proposed was effective for increasing the flexibility of the stretched muscles and the torque of the agonist (stretched) muscle groups and their antagonists.

Pain in workers with shoulder impingement syndrome: an assessment using the DASH and McGill pain questionnaires

OBJECTIVE: This study assessed physical function and pain in male and female workers with shoulder impingement syndrome using the Brazilian Portuguese versions of the Disabilities of the Arm, Shoulder and Hand (DASH) and McGill pain questionnaires. METHODS: Twenty-seven assembly line workers (18 men and 9 women; mean age of 33.26 ± 6.49 years) in the school supply industry were evaluated. The duration of the shoulder impingement pain was 31.74 ± 32.92 months and the amount of time of the workers in this industry was 11.08 ± 6.41 years. The DASH questionnaire was used to evaluate functional status and symptoms of the upper limbs of the workers. Using the McGill Pain Questionnaire, the pain was quantified by the number of words chosen and by the pain rating index (PRI). RESULTS: The women presented higher scores (P< 0.05) than the men for both DASH overall and DASH work scores. The women chose more words (17.00 ± 2.59) than the men (13.33 ± 3.16) and also presented the highest total PRI (P< 0.05). CONCLUSIONS: The results obtained in this group of Brazilian workers with shoulder impingement identify the most commonly used descriptors of shoulder pain. Further, this study shows that females are more likely than males to refer physical disability and pain. Also, the DASH and McGill pain questionnaires are important and helpful tools in the clinical evaluation of shoulder impingement syndrome.

OBJETIVO: Este estudo avaliou função física e dor em trabalhadores com síndrome do impacto através das versões brasileiras dos questionários "Disabilities of the Arm, Shoulder and Hand" (DASH) e McGill de dor. MÉTODO: Vinte e sete trabalhadores (18 homens e 9 mulheres; idade média de 33,26 ± 6,49 anos) de uma linha de produção de uma indústria de material escolar foram avaliados. O tempo de duração de dor no ombro era de 31,74 ± 32,92 meses e o tempo de trabalho na indústria era de 11,08 ± 6,41 anos. O questionário DASH foi utilizado para avaliar o estado funcional e os sintomas dos membros superiores dos trabalhadores. Através do questionário McGill de dor, a dor foi quantificada pelo número de palavras escolhidas e pelo índice de classificação da dor (ICD). RESULTADOS: As mulheres apresentaram maiores escores (P< 0,05) que os homens para ambos os módulos do DASH. As mulheres escolheram mais palavras (17,00 ± 2,59) que os homens (13,33 ± 3,16) e também apresentaram o maior ICD total (P< 0,05). CONCLUSÃO: Os resultados obtidos neste grupo de trabalhadores brasileiros com síndrome do impacto do ombro identificam os mais comuns descritores utilizados para dor no ombro. Além disso, este estudo mostra que as mulheres estão mais propensas a relatarem incapacidade física e dor quando comparadas aos homens. Os questionários DASH e McGill de dor são ferramentas importantes e úteis na avaliação clínica da síndrome do impacto do ombro.

Avaliação da amplitude articular do joelho: correlação entre as medidas realizadas com o goniômetro universal e no dinamômetro isocinético / Knee joint range-of-motion evaluation: correlation between measurements achieved using a universal goniometer and an isokinetic dynamometer

CONTEXTUALIZAÇÃO: O instrumento mais utilizado pelos terapeutas para mensuração da amplitude de movimento (ADM) articular é o goniômetro universal. No entanto, há carência de estudos que analisem a confiabilidade das medidas da ADM do joelho realizadas no dinamômetro isocinético. OBJETIVO: O objetivo deste estudo foi analisar a correlação entre as medidas de ADM na articulação do joelho, realizadas com o goniômetro universal e no dinamômetro isocinético. MÉTODO: Foram avaliados 38 voluntários saudáveis (27 mulheres, 11 homens), com idade de 36 ± 11 anos, com limitação mínima de 20° na ADM de extensão do joelho. No membro dominante de cada sujeito foram realizadas três mensurações da ADM do joelho com o goniômetro e três mensurações no dinamômetro. RESULTADOS: Os resultados deste estudo mostraram que há alto grau de correlação entre as medidas da ADM do joelho obtidas com o goniômetro universal e no dinamômetro isocinético (Coeficiente de Correlação de Pearson = 0,90). CONCLUSÃO: Com os procedimentos realizados, tanto o goniômetro universal como o dinamômetro isocinético podem ser utilizados para avaliação da ADM do joelho, pois ambos apresentam mensurações confiáveis.

Estudo anatomico e morfometrico do tendao do musculo subescapular: subsidios para a anatomia palpatoria do ombro / Anatomical and morphometric study of the subscapularis tendon: backing for palpatory anatomy of thr shoulder

As afeccoes do manguito rotador limitam o movimento humano e a avaliacao apropriada de suas estruturas e importante para o diagnostico e a reabilitacao dos individuos. No entanto, sao escassos os estudos morfometricos que fornecem detalhes sobre a localizacao topografica dessas estruturas. Objetivo: o presente estudo identificou a localizacao anatomica do tendao subescapular, um componente anterior do manguito rotador, em 3 posicoes usualmente utilizadas durante a palpacao para a avaliacao clinica: neutra, com o membro superior aduzido ao lado do torax (PN), antebraco fletido atras das costas (PAC) e antebraco fletido sobre o abdome (PAB). Metodo: foram dissecados 13 ombros de cadaveres adultos, de ambos os sexos. Nas posicoes adotadas foram mensuradas as distancias entre o tuberculo menor e o processo coracoide, assim como entre o tuberculo menor e o acromio. Resultados: as distencias do tuberculo menor ao processo coracoide nas posicoes PN, PAc, e PAB foram: 2,29 +-0,62 cm, 1,71+-0,52 cm, 1,27+-0,23 cm, respectivamente, com diferenca nas distancias da PN em relacao a PAC (p=0,01) e PAB (p=0,0001). As distancias do tuberculo menor ao acromio nas posicoes PN, PAC e PAB foram: 3,95+-0,59 cm, 4,96+-0,27 cm, e 4,04+-0,50 cm, respectivamente, com diferenca entre PN e PAC (p=0,0001) e entre PAC e PAB (p=0,0002). Foi identificada fusao do tendao do subescapular co o do supra-espinal e com a capsula articular. Algumas fibras tendinosas do musculo subescapular alcancam o ligamento transverso do umero. Conclusoes: Os resultados deste estudo mostram que a maior exposicao do tendao do subescapular ocorre na posicao neutra

Cardiopulmonary exercise testing in children with heart failure secondary to idiopathic dilated cardiomyopathy.

STUDY OBJECTIVE: To determine and compare the cardiopulmonary responses of healthy children and children with heart failure due to idiopathic dilated cardiomyopathy (IC) to progressive treadmill exercise testing. SETTING: University teaching hospital specializing in cardiology. PATIENTS OR PARTICIPANTS: Twenty-six children with stable, chronic heart failure (left ventricular ejection fraction < 45%) caused by IC (IC group) and 12 healthy children (control group). INTERVENTIONS: After 12-lead resting ECG, all children underwent progressive treadmill exercise testing using a modified Naughton protocol. Tests were performed in a controlled-temperature exercise facility, at least 2 h after a light meal. MEASUREMENTS AND RESULTS: Cardiopulmonary parameters were assessed at rest, at anaerobic threshold (AT), and at peak exercise. At rest, the tidal volume (VT) and O(2) consumption (VO(2)) for heart rate (O(2) pulse) were lower, while the heart rate, respiratory rate, and ventilatory equivalent for O(2) (minute ventilation [VE]/VO(2)) were higher in the IC group compared with the control group. At AT, the systolic BP, O(2) pulse, VT, exercise duration, VO(2), CO(2) production (VCO(2)), and VE were lower, while the VE/VO(2) and ventilatory equivalent for CO(2) (E/CO(2)) were higher in the IC group (p < 0.05). At peak exercise, the IC group had a significantly lower systolic BP, O(2) pulse, VE, VT, exercise duration, VO(2), and VCO(2), but higher VE/VO(2) and VE/VCO(2) than the control group (p < 0.05). The VE/VCO(2) slope was significantly higher for the IC group. No correlation existed between variables evaluated at rest vs during exercise. CONCLUSIONS: Gas exchange analysis performed during exercise successfully differentiated children with heart failure from healthy children.

Heart transplantation in neonates and children. Intermediate-term results.

OBJECTIVE: To assess intermediate-term outcome in children who have undergone orthotopic heart transplantation. METHODS: We carried out a longitudinal and prospective study between October '92 and June '99 comprising 20 patients with ages ranging from 12 days to 7 years (mean of 2.8 years). We employed a double immunosuppression protocol with cyclosporine and azathioprine and induction therapy with polyclonal antithymocyte serum. Survival and complications resulting from the immunosuppression protocol were analyzed. RESULTS: The double immunosuppression protocol and the induction therapy with polyclonal antithymocyte serum resulted in an actuarial survival curve of 90% and 78.2% at 1 and 6 years, respectively, with a mean follow-up period of 3.6 years. One patient died due to acute rejection 40 days after transplantation; another patient died 2 years after transplantation due to lymphoproliferative disorder; a third patient died because of primary failure of the graft; and a fourth patient died due to bronchopneumonia. The major complications were as follows: acute rejection, infection, nephrotoxicity, and systemic hypertension. The means of rejection and infection episodes per patient were 2.9 and 3.4, respectively. After one year of transplantation, a slight reduction in the creatinine clearance and systemic hypertension were observed in 7 (38.9%) patients. CONCLUSION: Heart transplantation made life possible for those patients with complex congenital heart diseases and cardiomyopathies in refractory congestive heart failure constituting a therapeutical option for this group of patients in the terminal phase.

Arritmias em crianças / Cardiac arrhythmias in children

Neste artigo apresentam-se as arritmias mais encontradas na criança e no adolescente. Enfoca-se sob a óptica do cardiologista pediátrico, enfatizando-se o diagnóstico da arritmia e a conduta terapêutica.

[Hemodynamic evaluation and clinical outcome of children with severe dilated cardiomyopathy eligible for heart transplantation]. / Avaliação hemodinâmica e evolução clínica de crianças portadoras de cardiomiopatia dilatada grave candidatas a transplante cardíaco.

PURPOSE: To evaluate hemodynamic parameters and clinical outcome of children with severe cardiomyopathy who are candidates for heart transplantation. METHODS: Twenty four children aged from 4 months to 10 years and 8 months (mean 3.7 +/- 2.5 years) from February 1992 to May 1996, were submitted to hemodynamic study and the following parameters were measured: cardiac output, mean pulmonary artery pressure (MPAP) and capillary wedge pressure. The pulmonary vascular resistance index (PVRI) and transpulmonary pressure gradient (TGP) were calculated. RESULTS: Ten (41.6%) children were transplanted (group A), 5 (20.8%) are still waiting heart transplantation (group B) and 9 (37.6%) died (group C). The mean age of the B and C group were significantly different. The PVRI, MPAP and TPG were significant lower in group A than group C (p = 0.01; p = 0.044 and p = 0.023 respectively). CONCLUSION: The profile of the hemodynamic parameters of children with severe dilated cardiomyopathy was compatible with the clinical findings. The age was the only difference comparing groups B and C. PVRI, MPAP and TPG were significant factors between group A and C. The older the patient, the worse was the prognosis.

[Neonate and infant heart transplantation]. / Transplante cardíaco neonatal e infantil.

PURPOSE: Heart transplantation has offered children with complex congenital heart diseases and severe cardiomyopathies a chance for survival. The present article was written to show the three year experience of this procedure at the Instituto do Coração-HCFMUSP. METHODS: The methodology used was based on heart transplant indication criteria, inclusion criteria for donors, postoperative management, immunosuppression and prophylaxis as well as treatment of potential complications. RESULTS: From November 1992 to November 1995, 11 children, aged 12 days old to six years (mean 2.5 years) underwent transplantation. Sixty percent of recipients were male; weight ranged from 3.5 to 17.8 kg (mean 10.3 kg). The mean age of donors was 4.4 years (a range of three weeks to ten years), 80% male, weight ranging from 3.8 to 20 kg (median 14.3 kg). The survival rate was 91% and the remaining 10 children are doing well. The most important complications were systemic hypertension, acute rejection and infection. The number of rejections and infections per patient were 3.5 and 4.7 episodes, respectively. The follow-up was between one month to three years (average 16 months). CONCLUSION: In this experience, heart transplantation has given an additional opportunity for children with complex congenital heart diseases and cardiomyopathies, with a survival rate of 91% in three years.

Favorable effects of immunosuppressive therapy in children with dilated cardiomyopathy and active myocarditis.

Among 68 children with severe dilated cardiomyopathy, 43 (aged 10 months to 15 years) presented with active myocarditis, diagnosed by endomyocardial biopsy. They were divided into four treatment groups: I, controls: 9 patients submitted to conventional treatment (digitalis, diuretics, and vasodilators) for 8.1 +/- 0.7 (SD) months; II, prednisone: 12 patients received conventional therapy plus prednisone; III, azathioprine: 16 patients submitted to conventional therapy plus prednisone and azathioprine; IV, cyclosporine: 13 patients treated with conventional therapy plus prednisone and cyclosporine. Immunosuppressive therapy was maintained for a mean of 8.4 +/- 1.2 months. They were submitted to noninvasive (electrocardiogram, chest radiograph, Doppler echocardiogram, and radioisotopic scintigraphy) and invasive (hemodynamic) studies. In the control group only 2 of 9 patients showed clinical and hemodynamic improvement and 1 of 4, histologic regression of the myocarditis. Among patients submitted to conventional therapy plus prednisone, 3 of 12 presented clinical and hemodynamic improvement; 2 of 5 also showed histologic regression of inflammatory process. By contrast, patients treated with azathioprine or cyclosporine associated with prednisone had significantly better results: 13 of 16 and 10 of 13 patients, respectively, had clinical and hemodynamic improvement; all 6 patients in the azathioprine group and all 4 patients in the cyclosporine group had histologic regression of the myocarditis. Two patients in the prednisone group, one in the azathioprine group, and one in the cyclosporine group died during treatment, in cardiogenic shock. In our experience immunosuppressive therapy with azathioprine or cyclosporine associated with prednisone improves the prognosis of children with active myocarditis and severe ventricular dysfunction.

[Immunosuppressive drugs for the treatment of active myocarditis in children. Hemodynamic evaluation]. / Drogas imunossupressoras no tratamento da miocardite ativa na criança. Avaliação hemodinâmica.

PURPOSE: To analyse hemodynamic parameters (left ventricles ejection fraction, cardiac index, mean pulmonary wedge pressure and left ventricle diastolic diameter, in a group of children with active myocarditis (diagnosed by endomyocardial biopsy) pre and post treatment with conventional therapy and immunosuppressive drugs (isolated prednisone or prednisone associated with azathioprine or cyclosporine). PATIENTS AND METHODS: Forty-four pediatric patients with active myocarditis were studied. Twenty males and 24 females from 10 months to 15 years old (median = 1.3 years). All patients were submitted to hemodynamic study and endomyocardial biopsy. The hemodynamic parameters mentioned above were analysed before and after the proposed therapy. The patients were distributed in group according to the admission in the protocol, group I (9 pts)--conventional therapy (CT); group II (12 pts)--CT plus prednisone; group III (16 pts)--CT plus prednisone plus azathioprine; group IV (13 pts)--CT plus prednisone plus cyclosporine. RESULTS: Forty-four patients were submitted to four different groups of therapeutic protocol. The hemodynamic parameters were analysed in each of them. Left ventricle ejection fraction were no significantly different in the pre and post therapeutic scheme in group I and II, they were significantly higher (p less than 0.05) in group III and IV. The same happened with cardiac index. The mean pulmonary wedge pressure no presented statistical differences in group I and II before and after treatment but significantly lower lends were observed in group III and IV. The same behavior were noted in the left ventricle end diastolic diameter. CONCLUSION: The association of azathioprine or cyclosporine to prednisone presented better results in the left ventricle function, when compared with conventional drugs or isolated use of prednisone, based in the analysis of same hemodynamic parameters.

Correlation between gallium-67 imaging and endomyocardial biopsy in children with severe dilated cardiomyopathy.

Fourty-four patients (aged 10 months to 15 years) were assessed in a double-blind study to observe the correlation between myocardial uptake of 67-gallium and endomyocardial biopsy in the detection of moderate to severe myocardial inflammation. The sensitivity and specificity of gallium-67 imaging were 87 and 81%, respectively. Based on these findings, immunosuppressive therapy can be assigned to children with dilated cardiomyopathy and positive myocardial uptake, since moderate and severe myocardial inflammation may be detected by this non-invasive method.

[Histologic response of the myocardium to various immunosuppressor schedules in patients with dilated cardiomyopathy and diagnosis of myocarditis at endomyocardial biopsy]. / Resposta histológica do miocárdio a diferentes esquemas imunossupressores em pacientes com cardiomiopatia dilatada e diagnóstico de miocardite biópsia endomiocárdica.

PURPOSE: To analyse the histological evolution of endomyocardial biopsies from children with active myocarditis, submitted or not to immunosuppressive therapy. PATIENTS AND METHODS: Four groups of patients were compared, clinically treated as follows: group I--anticongestive drugs (4 patients); group II--prednisone (5 patients); group III--prednisone plus azathioprine (9 patients); group IV--prednisone and cyclosporine (5 patients). RESULTS: No patient from group I presented any histological improvement during a mean period of 9 months, while evident histological improvement occurred in 25% of patients from group I, 67% from group III and 80% from group IV. The microscopical aspect of resolving myocarditis was only observed in patients from groups III and IV, after treatment. CONCLUSION: The immunosuppressive therapy with azathioprine or cyclosporine plus prednisone leads to decrease of active myocarditis intensity in a higher proportion of cases than the treatment with only prednisone or no immunosuppressive drugs.

[Endomyocardial biopsy and myocardial imaging with 67-gallium in the diagnosis of active myocarditis in children with dilated myocardiopathy]. / Biópsia endomiocárdica e mapeamento miocárdico com gálio-67 no diagnóstico de miocardite ativa em crianças portadoras de miocardiopatia dilatada.

PURPOSE: This study was designed to compare 67Ga imaging and endomyocardial biopsy (EB) in children with severe dilated cardiomyopathy (DC), as well as to evaluate the results in a group of patients with active myocarditis submitted to immunosuppressive therapy. PATIENTS AND METHODS: Forty-four pediatric patients with severe DC were studied. Twenty males and 24 females from 10 months to 15 year old (median = 2.6 years). All patients were submitted to a protocol including 67Ga uptake and EB. In patients submitted to immunosuppressive therapy these procedures were repeated after six months. RESULTS: In 32 patients (72.7%) the EB revealed presence of inflammatory process; 21 (65.6%) of these had a positive 67Ga uptake and 11 (34.4%) negative. Twelve patients with no evidence of inflammatory process in the EB, nine (75%) presented negative 67Ga uptake. However, when the intensity of myocardial inflammatory was analysed (mild, moderate and severe) and correlated with 67Ga imaging, was observed that the majority of patients with negative 67Ga uptake (11 patients) had mild inflammatory infiltration (nine patients). In this way the 67Ga uptake demonstrated a good correlation in the diagnosis of moderate and severe inflammatory process in children with DC. This is important because the use of immunosuppressive drugs is indicated only in these group. CONCLUSION: The 67Ga imaging is a noninvasive diagnostic method with a good sensitivity to the diagnostic method with a good sensitivity to the diagnosis of AM in children with severe DC, demonstrating to be very useful in the therapeutic approach.

[Primary rhabdomyosarcoma of the heart in children. A case report]. / Rabdomiosarcoma primário do coração em criança. Relato de caso.

The authors report a case of a child, 10 years old with a primary rhabdomyosarcoma of the heart that obstructed both caval veins. The clinical picture that lasted just three months before the admission was characterized by persistent fever, accentuated loss of weight and a very deteriorated general aspect. We emphasize the clinical aspects and other subsidiary elements that easily allowed to make the precise diagnosis in life as well as the therapeutic measures and follow up, besides a review of the literature, where it was confirmed the rarity of this pathological entity.