[Posterior Tibial Slope as a Morphological Risk Factor for Anterior Cruciate Ligament Reconstruction: a Retrospective Cohort Study]. / Zadní sklon tibie jako rizikový morfologický faktor kolena u náhrady PZV: hodnocení souboru pacientu.

PURPOSE OF THE STUDY Increased tibial slope facilitates anterior translation of tibia relative to the femur, thereby increasing the load on both the native and replaced anterior cruciate ligament. This study aims to retrospectively review the posterior tibial slope in a cohort of our patients after the ACL reconstruction and revision ACL reconstruction. Based on the results obtained by measurements, we aimed to confirm or disprove the claim that the increased posterior tibial slope is one of the risk factors of the ACL reconstruction failure. Another aim of the study was to assess whether there are any correlations between the posterior tibial slope and basic somatic parameters (height, weight, BMI) or the patient s age. MATERIAL AND METHODS The posterior tibial slope was measured retrospectively on lateral X-rays of 375 patients. There were 83 revision reconstructions and 292 primary reconstructions performed. The patient s age at the time of injury, height and weight were recorded and the BMI was calculated. The findings were then statistically analysed. RESULTS The mean posterior tibial slope in 292 primary reconstructions was 8.6 degrees, whereas the mean posterior tibial slope in 83 revision reconstructions was 12.3 degrees. The difference between the studied groups was statistically (p<0.0001) and substantively significant (d=1.35). In the breakdown into men and women, the mean tibial slope was 8.6 degrees in the group of men with primary reconstruction and 12.4 degrees in the group of men with revision reconstruction (p < 0.0001, d = 1.38). A similar result was achieved in women where in the group with primary reconstruction the mean tibial slope was 8.4 degrees, while in the group with revision reconstruction it was 12.3 degrees (p < 0.0001, d = 1.41). Furthermore, a higher age in men at the time of revision surgery (p = 0.009; d = 0.46) and a lower BMI in women at the time of revision surgery (p = 0.0342; d = 0.12) were observed. Conversely, neither height nor weight were different, both when comparing the whole groups and the groups in a breakdown by sex. DISCUSSION As regards the main aim, our results are in line with the results reported by majority of other authors, and they are substantively significant. The posterior tibial slope is a significant risk factor in anterior cruciate ligament replacements, with tibial slope above 12 degrees increasing the risk of ligament failure, namely both in men and women. On the other hand, this is obviously not the sole cause of the ACL reconstruction failure since there are also other risk parameters. It is not yet clear whether it makes sense to indicate correction osteotomy before the ACL replacement in all patients with an increased posterior tibial slope. CONCLUSIONS Our study confirmed a greater posterior tibial slope in the revision reconstruction group compared to the primary reconstruction group. Thus, we confirmed that greater posterior tibial slope may be a factor leading to the ACL reconstruction failure. Since the posterior tibial slope is easily measured on the baseline X-rays, we recommend to perform this measurement routinely before each ACL reconstruction. In the case of a high posterior tibial slope, slope correction should be considered to prevent potential ACL reconstruction failure. Key words: anterior cruciate ligament reconstruction, ACL graft failure, morphological risk factors, posterior tibial slope.

The effect of antibiotic versus no treatment at dry-off on udder health and milk yield in subsequent lactation: A retrospective analysis of Austrian health recording data from dairy herds.

Bovine mastitis is the most commonly diagnosed disease of dairy cows worldwide and causes extensive economic losses to milk producers. Intramammary infection status before dry-off plays a decisive role with respect to udder health and milk yield in the subsequent lactation. The aim of this study was to compare the effect of antibiotic dry cow therapy (DCT) versus no treatment at dry-off on milk yield, somatic cell count (SCC), inflammation of the mammary gland (IMG), and the incidence of clinical mastitis in the subsequent lactation. Dairy herd data from 251 Austrian dairy farms were recorded over an observation period of 12 mo and subsequently analyzed. The data set included 5,018 dairy cows: 2,078 were treated with antibiotics (abDCT group) and 2,940 were not treated (noDCT group) at dry-off. The abDCT group was subdivided, based on the antimicrobial active substances used for drying off, into 4 different groups (penicillins, cloxacillin, cephalosporins, and rifaximin). Based on bacteriological culture results, infections were grouped into those caused by major, minor, and other pathogens. Additionally, the IMG was defined via SCC from milk recording data using a cutoff of 200,000 cells/mL before drying off and after calving. The incidence of clinical mastitis cases within 30 and 90 d in milk was calculated using veterinary diagnosis data. To investigate the effect of different dry cow therapies on the following parameters: milk yield, SCC, and diagnosed clinical mastitis cases, different linear mixed models were constructed. Overall, the abDCT group was determined to have a significantly higher milk yield over 305 d in milk in the subsequent lactation (increase of 6.18%), compared with the noDCT group (increase of 4.29%). Both groups (abDCT and noDCT) demonstrated a decrease in the first SCC after calving compared with the SCC before dry-off, although the treated cows had a significantly higher reduction. Regarding the different antibiotic groups, with exception of the rifaximin treated cows, all antibiotic groups showed a significant difference from not treated cows with respect to SCC. Additionally, we were able to demonstrate that cows with IMG before dry-off had a 2.073 times higher chance of an increased SCC (>200,000 cells/mL) after calving. With respect to the veterinary diagnosis data, neither the IMG before drying off nor the type of DCT had a significant influence on the probability of developing clinical mastitis within 30 or 90 d in milk. Only a small number of treatments was accompanied with a bacteriological examination before drying off. However, the existing data in this study indicates that the intramammary infection status before dry-off in combination with different dry cow treatments influences udder health and milk yield after calving. Nevertheless, further studies with larger data sets of bacteriological examinations are necessary to enable a more in-depth investigation into the effects of different antibiotic substances used for DCT.

[Arthroscopic Superior Capsule Reconstruction with a Long Head of the Biceps Tendon Autograft: One-Year Follow-up Results]. / Rocní klinické výsledky artroskopické rekonstrukce horní kapsuly ramenního kloubu pomocí slachy dlouhé hlavy bicepsu.

PURPOSE OF THE STUDY: Superior Capsule Reconstruction (SCR) of the shoulder joint has recently been included in the portfolio of interventions as a solution to irreparable rotator cuff tears. One of the options is to use a long head of the biceps tendon (LHBT) autograft. This paper presents the fi rst clinical outcomes of the SCR of the shoulder joint using the LHBT autograft. MATERIAL AND METHODS It is a prospective non-randomised study in which 14 patients were included, namely 7 men and 7 women. The patients were evaluated using the pain VAS, UCLA (The University of California at Los Angeles) Shoulder Rating Scale and ASES (The American Shoulder and Elbow Surgeons) Shoulder Score. The minimum follow-up was 12 months after surgery. The measured values were analysed using the standard statistical methods. RESULTS From August 2020 to January 2022, a total of 14 SCR with biceps tendon autograph were performed at our department. The mean age of the patients was 62 years (40-72). The mean value of the UCLA Shoulder Score was 12.36 ± 2.92 points preoperatively, while after surgery the obtained values increased to the mean value of 28.86 ± 3.08 points. The ASES score was 25.48 ± 3.89 points preoperatively and 82.41 ± 7.95 points at one year after surgery. The preoperative mean VAS score was 6.14 ± 1.10 points and 1.36 ± 0.93 points at one year after surgery. The mean active shoulder fl exion measured preoperatively was 140 degrees, whereas at one year after surgery it was 171 degrees. The mean active abduction reached 123 degrees before surgery and 169 degrees after surgery. The mean active external rotation of the shoulder joint was 59 degrees preoperatively and 52 degrees postoperatively. The mean active external rotation at 90 degrees of abduction was 52 degrees preoperatively and 60 degrees postoperatively. Whereas the improvement as against the preoperative status measured by the UCLA, ASES and pain VAS was signifi cant, the differences in the range of motion were signifi cant in the case of active fl exion and abduction only. DISCUSSION Painful irreparable rotator cuff tear constitutes an indication for SCR. The reconstruction is performed using autografts, allografts and xenografts. In literature, several SCR surgical techniques using a long head of the biceps tendon have been presented. In most of these techniques the supraglenoid insertion of the LHBT was left intact. Our study showed a signifi - cant relief from problems and good functional outcomes at 1 year after surgery when the biceps tendon had been used. Similar results are reported also by other studies using the biceps tendon for SCR. When comparing this study and the other study we published earlier on SCR with xenografts, there is no signifi cant difference in the clinical outcomes between these two techniques. On the very contrary, they are slightly better in some parameters. CONCLUSIONS Arthroscopic SCR of the shoulder joint with the biceps tendon reports good clinical outcomes at one year after surgery both with regard to the relief from problems and range of motion. Due to low morbidity of graft harvesting, low cost, and easy surgical technique, it appears to be the fi rst-choice method for superior capsule reconstruction of an irreparable tear of supraspinatus or infraspinatus if the long head of the biceps tendon is preserved. A longer follow-up period and evaluation of a larger study population would be necessary to defi nitely confi rm the success rate of the described procedure. KEY WORDS: massive rotator cuff tears, irreparable rotator cuff tears, superior capsular reconstruction, autograft, long head of the biceps tendon.

Changes in the body composition of boys aged 11-18 years due to COVID-19 measures in the Czech Republic.

BACKGROUND: The lockdown measures related to coronavirus disease 2019 (COVID) impacted the health of adolescents by reducing physical activity (PA). The physical changes in response to decreases in PA can be measured with full body composition analysis. The aim of this study was to evaluate the effects of long-term PA restrictions on body fat (BF), fat-free mass (FFM) and skeletal muscle mass (SMM) in adolescents. METHODS: A total of 1669 boys (before PA restriction (G1): 998; after PA restrictions ended (G2): 671; between the ages of 11 and 18 were included. The measured parameters were body mass (BM), visceral fat area (VFA), BF, FFM and SMM. The whole-body composition was evaluated using bioelectrical impedance analysis (BIA). RESULTS: Compared to G1, G2 exhibited an increase in BF between 1.2 and 5.1%. This difference was significant in boys aged 13 to 18 years (p < 0.05). VFA increased between 5.3 and 20.5 cm2; this increase was significant in boys aged 13 to 18 years (p < 0.05). SMM decreased between 2.6 and 3.8%, and this decrease was significant in all age groups (p < 0.05). Changes in body composition were not accompanied by any significant changes in BM. CONCLUSIONS: COVID-19 restrictions reduced PA, resulting in a significant decrease in SMM. This decrease may impact boys' ability to engage in sufficiently varied PA, which may lead to a further decline in PA and subsequent medical consequences in adulthood.

[Effect of a Single Dose of Tranexamic Acid Administered during Anterior Cruciate Ligament Reconstruction Using Hamstrings: a Randomized Clinical Study]. / Efekt jednorázového podání kyseliny tranexamové pri rekonstrukci predního zkrízeného vazu hamstringy: randomizovaná klinická studie.

PURPOSE OF THE STUDY Anterior cruciate ligament reconstruction is one of the most common reconstruction surgeries. The unintended consequences of the surgery are hemarthrosis, blood loss, knee swelling and postoperative pain. The purpose of the study was to evaluate the effect of a single dose of intravenous tranexamic acid (TXA) on the postoperative parameters and functional status of the knee joint 3 months after surgery. MATERIAL AND METHODS It is a prospective randomised clinical study. An intravenous injection of TXA equivalent to 15 mg/kg in 100 ml of saline solution was administered to the test group during the surgery (20 minutes before the end of the surgery). The control group was administered 100 ml of saline solution without TXA. In both groups, the following parameters were evaluated preoperatively and postoperatively (on Day 1 and Day 10 and at 1 month and 3 months): thigh circumference at 1 cm above the patella, Coupens and Yates (CY) score for swelling, and pain score (VAS). At 24 hours after the surgery, the blood loss (secretion into the drain) and decrease in hemoglobin (Hb) and hematocrit (HCT) levels compared to the preoperative levels were assessed. The functional status of the knee joint was assessed based on the Lysholm knee scoring scale and the IKDC subjective knee evaluation form preoperatively, or at 1 and 3 months postoperatively. RESULTS In the test group, a significantly lower blood loss was detected 24 hours after the surgery. The mean difference of 128 ml compared to the control group was both statistically and practically significant (p < 0.001, d =1.42). The test group showed a lower decrease in Hb and HCT levels postoperatively compared to the control group, although with no statistical significance. On the first postoperative day, slightly better results of the thigh circumference at 1 cm above the patella and of the CY score were observed in the test group. However, during the follow-up check performed postoperatively on Day 10, the differences in the thigh circumference at 1 cm above the patella, CY score and pain VAS score were negligible. The differences in the functional status of the knee joint between the two groups ascertained during the check performed 1 month and 3 months after the surgery were insignificant. DISCUSSION Our study, just like other studies, confirms a significant effect of a single dose of intravenous TXA on the volume of blood loss and early postoperative swelling, which are the parameters affecting the early postoperative course. Even though the intervention does not affect the subsequent result of surgery, it can undoubtedly be of benefit perioperatively. There is a fairly limited number of randomised clinical studies on this topic in literature, with most of them published in the last 7 years. Further research should, among other things, optimise the protocol and identify a suitable candidate for TXA administration in patients undergoing an ACL reconstruction. CONCLUSIONS Our study confirmed the positive effect of a single dose of intravenous TXA during the reconstruction of anterior cruciate ligament using hamstrings on early postoperative blood loss and early postoperative swelling, which can have a positive effect on wound healing and prevent postoperative complications. Therefore, in agreement with available literature, we recom mend administering a single dose of intravenous TXA in ACL reconstruction, unless there is a contraindication to this therapy. Key words: anterior cruciate ligament reconstruction, hamstrings tranexamic acid, single intravenous administration, clinical evaluation.

[Incidence, Morphology and Clinical Significance of Hill-Sachs Lesions in Shoulder Instability - CT Scan Evaluation of the Group of Patients]. / Incidence, morfologie a klinický význam HillovýchSachsových lézí u nestabilních ramenních kloubu ­ CT hodnocení souboru pacientu.

PURPOSE OF THE STUDY Shoulder instability is often times accompanied by associated injuries caused by the humeral head displacement. These are primarily bone lesions on the head and socket of the glenohumeral joint. The purpose of this study was to evaluate the frequency, morphology and clinical significance of bone lesions in shoulder instabilities in a group of patients operated in our department for glenohumeral instability between 2012 and 2019. MATERIAL AND METHODS The ongoing evaluation included 373 patients with trauma and habitual instability who had undergone surgery in our department in the period from 2012 to 2019. All patients underwent a preoperative 3D CT scan of the shoulder joint. Subsequently, the morphology and clinical significance of individual bone lesions were evaluated based on the older Burkhart s concept of engaging/nonengaging lesions and the newer concept of glenoid track by Yamamoto and Di Giacomo of 2007, 2014 or 2020. RESULTS The frequency of Hill-Sachs lesion was 83.4% (311) in our group of patients. In nearly two thirds (211 cases) also a bone defect on glenoid was detected (59.3%). When comparing the basic types of instabilities, in the TUBS group the Hill-Sachs lesions were present up to twice as often as in the group with AMBRI instability. Clinically significant Hill-Sachs lesions according to the older concept of engaging/ nonengaging lesions of Burkhart were reported in 104 cases (34%). Clinically significant lesions according to the newer concept of Yamamoto and DiGiacomo (the so-called off-track lesions) were observed in 173 cases (55.6%). Classified as critical were the clinically insignificant lesions (the so-called on-track lesions), which by their location were near the glenoid track. These lesions were found in 80 patients. After adding up the significant (off-track) and critical on-track lesions, we arrived at 253 (81.4%) clinically significant lesions based on the updated Yamamoto concept. DISCUSSION The frequency of Hill-Sachs lesions and glenoid defects identified by us is close to the upper limit of the range described in literature (8 to 100%). Based on the recent study by Yamamoto, added to these defects were the so-called peripheral ontrack defects, the clinical significance of which is currently indisputable. The oldest classification into engaging/nonengaging lesions revealed only 34% of the significant lesions, but this concept does not evaluate the glenoid defect. The newer concept by Yamamoto/DiGiacomo resulted in detecting 55.6% of significant Hill-Sachs lesions. The latest modification of the glenoid track of 2020, which includes also the on-track lesions in the critical zone among the significant lesions, in our group of patients classified 81% of lesions as clinically significant. CONCLUSIONS Our study confirmed the very frequent occurrence of clinically significant Hill-Sachs lesions in shoulder instabilities. Therefore, for the sake of successful shoulder stabilisation surgery detailed preoperative planning with 3D CT of the shoulder joint and evaluation of the associated bone lesions are necessary. The highest detection of clinically significant lesions was achieved by the latest modification of the glenoid track concept. Future studies will have to prove the effect of this classification on the result of surgical treatment. Key words: shoulder instability, glenoid track; bone defects, Hill-Sachs lesion; bipolar lesions; 3D CT evaluation.

[InternalBrace ACL Repair - First Experiences and Outcomes]. / První výsledky a klinické zkusenosti s metodou InternalBrace u lézí LCA.

PURPOSE OF THE STUDY In recent years attempts have been made again to repair anterior cruciate ligament (ACL) in order to maintain native kinematics and knee joint proprioception. The method of choice is the arthroscopic suture of the ligament using the InternalBrace ligament augmentation. This study presents the first experience gained with this surgical technique and the clinical outcomes. MATERIAL AND METHODS In the period from November 2016 to December 2018, a total of 46 patients with acute ACL rupture underwent the ACL repair using the InternalBrace ligament augmentation. This study includes only the patients followed up for a minimum period of 12 months postoperatively. For the evaluation of patients, the well-established clinical scores were used - the Tegner Activity Level Scale, the IKDC (International Knee Documentation Committee) subjective scale and the Tegner Lysholm Knee Scoring Scale. The measurements were taken preoperatively and at 6 and 12 months postoperatively. RESULTS The evaluations concerned 20 patients who had undergone surgery in the period from February 2017 to February 2018. In the aforementioned group of patients, there were 3 cases of reconstruction failure (15%), subsequently requiring the ACL reconstruction. The average preoperative Tegner Activity score was 8.2 (6-10; median 8.0). At six months postoperatively, the average value of this score was 7.35 (5-10; median 7), and at 12 months postoperatively it was 7.35 (4-10; median 7). The average preoperative Lysholm score was 66.4 (16-100; median 69). At six months postoperatively, the average value of this score improved to 90.70 (71-100; median 92) and at 12 months postoperatively to 91 (75-100; median 90). The average IKDC subjective score before the surgery was 49.8 (36-74; median 49). At six months postoperatively the average achieved score was 87.70 (71-99; median 90) and at 12 months postoperatively it was 88.9 (63-99; median 93). The differences between the preoperative values and the values at 6 months after the surgery were significant in all the followedup parameters. Conversely, the differences between the values at 6 and at 12 months were not significant. DISCUSSION The clinical outcomes of the patients after the ACL repair are valuable and comparable to the data published in literature. They were largely achieved within 6 months after the surgery. A fairly high percentage of failure of this method compared to literature (Jonkergouw 7.5%, McKay 1.5%) can partly be ascribed to the learning curve even though the surgeries were performed exclusively by experienced surgeons. A certain role could also be played by more challenging indication for this procedure or a faster return to postoperative load. CONCLUSIONS Anterior cruciate ligament suture with the InternalBrace ligament augmentation judging from the results achieved by our group of patients brings very good clinical outcomes already at 6 months postoperatively. This method allows the athletes to return to full load soon. It maintains the kinematics and knee joint proprioception, and thus can potentially contribute to the prevention of post-traumatic arthritis. Strict application of indication criteria is a precondition to success. A longer follow up and evaluation of a larger number of patients will, however, be necessary to definitely confirm the success of this surgical technique. Key words: arthroscopy, ACL rupture, ACL repair, InternalBrace, clinical evaluation.

Training-induced changes in physical performance can be achieved without body mass reduction after eight week of strength and injury prevention oriented programme in volleyball female players.

The purpose of the study was to analyse the changes in muscle strength, power, and somatic parameters in elite volleyball players after a specific pre-season training programme aimed at improving jumping and strength performance and injury prevention. Twelve junior female volleyball players participated in an 8-week training programme. Anthropometric characteristics, isokinetic peak torque (PT) single-joint knee flexion (H) and extension (Q) at 60º/s and 180º/s, counter movement jump (CMJ), squat jump (SJ), and reactive strength index (RSI) were measured before and after intervention. Significant moderate effects were found in flexor concentric PT at 60º/s and at 180 º/s in the dominant leg (DL) (18.3±15.1%, likely; 17.8±11.2%, very likely) and in extensor concentric PT at 180º/s (7.4%±7.8%, very likely) in the DL. In the non-dominant leg (NL) significant moderate effects were found in flexor concentric PT at 60º/s and at 180º/s (13.7±11.3%, likely; 13.4±8.0%, very likely) and in extensor concentric PT at 180º/s (10.7±11.5%, very likely). Small to moderate changes were observed for H/QCONV in the DL at 60º/s and 180º/s (15.9±14.1%; 9.6±10.4%, both likely) and in the NL at 60º/s (moderate change, 9.6±11.8%, likely), and small to moderate decreases were detected for H/QFUNC at 180º/s, in both the DL and NL (-7.0±8.3%, likely; -9.5±10.0%, likely). Training-induced changes in jumping performance were trivial (for RSI) to small (for CMJ and SJ). The applied pre-season training programme induced a number of positive changes in physical performance and risk of injury, despite a lack of changes in body mass and composition.

[Progredient "pulmonary thromboembolism" in spite of sufficient anticoagulant therapy?]. / Progredienz einer "zentralen Lungenarterienembolie" unter therapeutischer Antikoagulation?

HISTORY AND ADMISSION FINDINGS: A 43-year-old woman presented with persistent dry cough and exertional dyspnoea for about 6 months. An outpatient CT scan of the chest led to the diagnosis of pulmonary thromboembolism. INVESTIGATIONS: The echocardiography showed signs of right ventricular load. Phlebothrombosis, thrombophilia or an active malignant disease were excluded. TREATMENT AND COURSE: An anticoagulant therapy was started in the hemodynamically stable patient. She was discharged in good condition. Four weeks later the patient was readmitted with worsening of symptoms. The CT scan showed progression of the findings in spite of sufficient anticoagulant therapy. Echocardiography revealed an increase of the right ventricular load. A systemic thrombolysis with 100 mg alteplase followed, but without any change. Subsequently, the suspicion of an intraluminal growing tumorous mass was confirmed. A tumor-endarterectomy with reconstruction of the left pulmonary artery together with a pericardial patch and an extensive pneumonectomy on the right were performed. Histopathologically and immunohistochemically a pulmonary artery sarcoma with the differentiation of a leiomyosarcoma was diagnosed. CONCLUSION: The primary pulmonary artery sarcoma is a rare disease and pulmonary thromboembolism must be considered for differential diagnosis. In the CT scan a low-attenuation filling defect occupying the entire luminal diameter of the pulmonary artery, expansion of the involved arteries or extraluminal tumor extension can lead to a suspected diagnosis. Furthermore in case of a progression of the findings under sufficient anticoagulant therapy a primary pulmonary sarcoma has to be considered as differential diagnosis. Complete surgical resection offers the only chance of cure.

Increased exercise ejection fraction and reversed remodeling after long-term treatment with metoprolol in congestive heart failure: a randomized, stratified, double-blind, placebo-controlled trial in mild to moderate heart failure due to ischemic or idiopathic dilated cardiomyopathy.

BACKGROUND: the effects of long-term administration of beta-blockers on left ventricular (LV) function during exercise in patients with ischemic heart disease (IHD) and idiopathic dilated cardiomyopathy (DCM) are controversial. PATIENTS AND METHODS: patients with stable congestive heart failure (CHF) (New York heart association [NYHA] class II and III) and ejection fraction (EF) < or =0.40 were randomized to metoprolol, 50 mg t.i.d. or placebo for 6 months. Patients were divided into two groups: ischemic heart disease (IHD) and idiopathic dilated cardiomyopathy (DCM). The mean EF was 0.29 in both groups and 92% were taking angiotensin-converting enzyme (ACE) inhibitors. In the IHD group, 84% had suffered a myocardial infarction (MI) and 64% had undergone revascularization at least 6 months before the study. LV volumes were measured by equilibrium radionuclide angiography. Mitral regurgitation was assessed by Doppler echocardiography. All values are changes for metoprolol subtracted by changes for placebo. RESULTS: metoprolol improved LV function markedly both at rest and during sub-maximal exercise in both groups. The mean increase in EF was 0.069 at rest (P<0.001) and 0.078 during submaximal exercise (P<0.001). LV end-diastolic volume decreased by 22 ml at rest (P=0.006) and by 15 ml during exercise (P=0.006). LV end-systolic volume decreased by 23 ml both at rest (P=0.001) and during exercise (P=0.004). Exercise time increased by 39 s (P=0.08). In the metoprolol group, mitral regurgitation decreased (P=0.0026) and only one patient developed atrial fibrillation vs. eight in the placebo group (P=0.01). CONCLUSION: metoprolol improves EF both at rest and during submaximal exercise and prevents LV dilatation in mild to moderate CHF due to IHD or DCM.

Capecitabine can induce acute coronary syndrome similar to 5-fluorouracil.

Capecitabine is a member of a new class of oral fluoropyrimidines. It is a 5-fluorouracil (5-FU) prodrug, activated by a series of enzymes. Activation has been demonstrated to occur preferentially in tumor tissue, which may explain the favorable balance of efficacy and toxicity of this drug. Cardiotoxicity, a rare but potentially serious adverse effect of 5-FU, has not been reported for capecitabine to date. Here we report a patient who experienced a severe and prolonged acute coronary syndrome during treatment with capecitabine. He had previously developed similar symptoms during treatment with infusional 5-FU. Capecitabine should thus be considered an agent with cardiotoxic potential. This adverse effect should be specifically monitored in all patients treated with capecitabine. Patients with symptoms suggestive of cardiotoxicity during previous treatment with a fluoropyrimidine should not be treated with capecitabine.

Immediate stent implantation versus conventional techniques for the treatment of abrupt vessel closure or symptomatic dissections after coronary balloon angioplasty.

BACKGROUND: Coronary stenting was initially designed to treat a bailout scenario. Prospective randomized trials comparing stent implantation with standard techniques, including emergency coronary artery bypass grafting, are lacking. The aim of this trial was to test the superiority of immediate stent implantation compared with standard techniques for the treatment of abrupt or threatening closure after coronary balloon angioplasty. METHODS: In a prospective trial, 100 patients with abrupt vessel closure or symptomatic dissections causing objective signs of ischemia were randomly assigned to treatment with immediate placement of stents (n = 51) versus standard techniques such as prolonged dilatation or emergency bypass surgery (n = 49). The primary end point was the achievement of successful stabilization not requiring crossover to the other study group. Secondary end points included event-free survival and restenosis. RESULTS: Successful stabilization was achieved in 94% of patients in the stent group compared with 78% of patients in the standard treatment group (P =.038). Two patients died in each group, and there was a trend toward a higher incidence of myocardial infarction (16% vs 8%; P =.163) and a significantly increased creatine phosphokinase level (245 IU/L [95% confidence interval, 217-265 IU/L] vs 179 IU/L [confidence interval 140-212 IU/L]; P =.0002) in the standard treatment group. Event-free survival after 250 days was 72% in the stent group compared with 29% in the standard treatment group (P =.001). The angiographic restenosis rate was 30% in the stent group versus 59% in the standard treatment group (P =.01). CONCLUSIONS: Immediate stenting, if technically feasible, shows superior short- and long-term results compared with standard treatment options.

MIC trial: metoprolol in patients with mild to moderate heart failure: effects on ventricular function and cardiopulmonary exercise testing.

UNLABELLED: Beta-blocker therapy results in a functional benefit in patients with heart failure (CHF) due to idiopathic dilated cardiomyopathy (DCM). This study assessed if similar effects were observed in patients with ischemic heart disease (CAD), NYHA II-III after 6 months of therapy with metoprolol. METHODS AND RESULTS: Fifty-two patients with CHF secondary to DCM (26 patients) and CAD (26 patients) and a left ventricular ejection fraction (EF)<40% were enrolled in the placebo-controlled study. The study medication was titrated over 6 weeks, the mean final dosage was 135 mg/day. Three patients died due to cardiogenic shock, two received placebo and one metoprolol. Eight patients did not complete the study due to non-compliance. Metoprolol significantly reduced heart rate at rest and after submaximal and maximal exercise. Vo(2)-max and Vo(2)-AT as well as the 6-min walk test improved significantly after metoprolol treatment. There was a significant increase in EF at rest (27.3-35. 2%), submaximal (28.5-37.7%) and maximal exercise (28.7-40.9%) in the metoprolol-treated patients. No differences were found between patients with CAD and DCM. We also observed reduced left ventricular volumes. CONCLUSION: The additional therapy with metoprolol improved cardiac function and the cardiopulmonary exercise capacity in patients with CHF.

[Value of spiro-ergometry and stress echocardiography on optimized programming of the upper frequency limit of dual chamber cardiac pacemakers]. / Stellenwert der Spiroergometrie und Stressechokardiographie zur optimierten Programmierung der oberen Grenzfrequenz von Zweikammerschrittmachern.

Patients with a dual chamber pacemaker often suffer from chronic heart failure. The influence of the upper tracking rate on cardiac performance in patients with and without congestive heart failure is unknown. Therefore, twenty patients with a dual chamber pacemaker implanted for high degree AV block were randomly programmed to upper tracking rates of 110, 120, and 130 bpm. Oxygen uptake (VO2), work capacity, and heart rate were determined at the anaerobic threshold (AT) and at peak exercise using spiroergometry every 4 weeks. Nine patients (71 +/- 12 years) had evidence for advanced heart failure (Weber C/D, group I); 11 patients (60 +/- 6 years) had no or only mild heart failure (Weber A/B, group II). Patients in group II achieved a higher mean VO2-AT at 130 bpm (17.3 +/- 3.9 ml/min/kg) than at 110 bpm (13.7 +/- 4.0 ml/min/kg; p = 0.001). Maximum oxygen uptake and work capacity at the anaerobic threshold were also significantly higher in group II with an upper tracking rate of 130 bpm than at 110 bpm (20.5 +/- 4.5 ml/min/kg vs. 18.2 +/- 5.3 ml/min/kg, p = 0.031, and 98 +/- 29 W vs. 86 +/- 27 W, p = 0.04). In group I, mean oxygen uptake at the anaerobic threshold (VO2-AT) was higher at 110 bpm (11.1 +/- 4.0 ml/min/kg) than at 130 bpm, although of only borderline statistical significance (9.2 +/- 2.6 ml/min/kg; p = 0.052). In group I a higher upper rate decreased VO2-AT by 24%, whereas in group II the higher upper rate improved aerobic capacity by 26%. Stressechocardiography (VVI pacing with a maximum tracking rate of 130 bpm) revealed new wall motion abnormalities in all patients of group I, but only in one patient of group II. Wall motion score index increased from 1.20 +/- 0.24 at rest to 1.54 +/- 0.28 under stress (p < 0.001) in group I, but not in group II (1.00 +/- 0 vs. 1.06 +/- 0.19; p = n.s.). Thus, carriers of dual-chamber pacemakers with no or mild heart failure (Weber A/B) benefit from higher programmed upper rates. In contrast, patients with more advanced heart failure (Weber C/D) improve aerobic capacity with lower programmed upper rates. This may be caused by exercise-induced ischemia in group I as indicated by stressechocardiography.

[Quantification of cell proliferation with the proliferation marker MIB-1 in endomyocardial biopsies after heart transplantation. An aid in diagnosis of graft rejection needing treatment?]. / Quantifizierung der Zellproliferation mittels des Proliferationsmarkers MIB-1 in endomyokardialen Biopsien nach Herztransplantation. Eine Hilfe bei der Diagnostik der therapiebedürftigen Abstossungsreaktion?

The histological grading of endomyocardial biopsies still represents the gold standard in the diagnosis of cardiac allograft rejections. Severe acute rejections (grade 3A/3B, ISHLT) after heart transplantation require immediate high-dose immunosuppressive therapy. The histomorphological differentiation to the rejection requiring no therapy (grade 2) is often difficult. The aim of this study is the improvement of the diagnostic identification of therapy-requiring rejections using quantification of cell proliferation in the inflammatory infiltrate of biopsies. 322 consecutive endomyocardial biopsies from 48 heart allograft recipients were immunohistochemically investigated using the monoclonal antibody MIB-1 binding selectively to the proliferation associated antigen Ki 67. Fifty percent of all biopsies showed cell proliferation: 47.0% in absent or mild rejection (0, 1A, 1B) compared to 88.0% in moderate to severe rejection (2, 3A/3B) (p < 0.01). Proliferating cells were arranged in a focal or perivascular pattern in 66.0% and diffuse in 34.0%. The quantity of proliferating cells per biopsy--but not the pattern--correlated with the grade of rejection: 0.7% in grade 0, 1.4%/5% in 1A/1B, 8.5% in grade 2 up to 18.7% in 3A/3B, and 2.7% in R1 (p < 0.01, ccorr = 0.65). The amount of proliferating mononuclear cells in the inflammatory infiltrate in acute cardiac allograft rejection is proportional to the severity of the rejection and thus an aid in the difficult histological differentiation of grade 3A/3B.

Halothane, but not isoflurane, impairs the beta-adrenergic responsiveness in rat myocardium.

BACKGROUND: The aim of this study was to identify the mechanisms by which halothane and isoflurane change the myocardial beta-adrenergic signal transduction pathway. METHODS: The authors investigated the influence of volatile anesthetics on the isometric force of contraction of rat papillary muscles. Concentration-response curves for isoproterenol and epinephrine were studied under control conditions and in the presence of halothane or isoflurane. In radioligand receptor-binding studies, the beta-adrenoceptor affinities for isoproterenol and epinephrine were investigated with and without guanosine triphosphate. In addition, the isoproterenol-induced cyclic adenosine monophosphate accumulations in viable cardiomyocytes in the absence and in the presence of halothane were determined by radioimmunoassays. RESULTS: The half-maximal positive inotropic effect of isoproterenol was reached at a half-maximal effective concentration (EC50 value) of 68 nM (33-141 nM; n = 10). A minimum alveolar concentration of 1.3 halothane reduced the positive inotropic potency of isoproterenol (EC50 = 158 nM [118-214 nM; n = 10; P < 0.01 vs. control]), whereas isoflurane did not changed it. This observation held true when the force of contraction was stimulated with epinephrine. Halothane (1.3 minimum alveolar concentration) depressed beta-adrenoceptor high-affinity binding and beta-adrenoceptor agonist affinity in radioligand binding assays, an effect not seen with isoflurane. Halothane shifted the intracellular cyclic adenosine monophosphate response curve of isoproterenol to the right. CONCLUSION: Halothane, but not isoflurane, impairs the beta-adrenergic responsiveness in rat myocardium by reducing the agonist affinity of the beta-adrenoceptors.

Quantitative assessment of transient regional ischemia during rotational atherectomy.

UNLABELLED: Sustained myocardial ischemia with angina pectoris, electrocardiographic changes and subsequent non-Q-wave infarctions has been reported during percutaneous transluminal rotational atherectomy of complex coronary lesions. The purpose of this study was to evaluate the effect of rotational atherectomy on regional myocardial perfusion as assessed by serial 99mTc-sestamibi SPECT imaging with semiquantitative tracer uptake analysis. METHODS: Twenty-nine consecutive patients with anginal symptoms, complex coronary lesions (all Type B and Type C) and preserved left ventricular function were studied using resting 99mTc-sestamibi SPECT before rotational atherectomy, during and 2 days after the procedure. For semiquantitative computerized analysis, the left ventricular myocardium was divided into 24 regions, and regional perfusion was expressed as percentage of maximal sestamibi uptake. RESULTS: Visual analysis of scintigraphic images revealed transient perfusion defects corresponding to the revascularized vessel in 26 of 29 patients, whereas three patients had no transient hypoperfusion. During rotational atherectomy, perfusion decreased significantly (>2 s.d. below normal mean) in 3.1 +/- 2.4 regions (range 1-10). Perfusion in the territory of the revascularized vessel was 75% +/- 11% at baseline, decreased to 67% +/- 12% during rotational atherectomy (p < 0.001) and normalized again after rotational atherectomy to 78% +/- 8% (p < 0.001). Similarly, perfusion in the region with the maximal reduction decreased from 74% +/- 15% at baseline to 55% +/- 14% (p < 0.001) during the procedure and returned to 74% +/- 16% (p < 0.001) following the intervention. In calcified stenoses, the extent of perfusion defects was larger as compared to noncalcified (4.2 +/- 2.5 versus 2.3 +/- 2.0 regions/patient, p < 0.05). CONCLUSION: During rotational atherectomy, myocardial hypoperfusion occurs. The transient nature of this perfusion defect can be demonstrated and quantified by serial 99mTc SPECT. This model may prove useful to assess the effects of pharmacological approaches to reducing myocardial hypoperfusion during coronary rotational atherectomy.

[Comparison of NYHA classification with cardiopulmonary function in patients with chronic heart failure]. / Vergleich der NYHA-Klassifikation mit der kardiopulmonalen Funktion bei Patienten mit chronischer Herzinsuffizienz.

In this study a correlation was sought between the NYHA class, the results of cardiopulmonary exercise testing (CPX) and the ejection fraction (EF) measured by echocardiography and scintigraphy. Of 36 patients enrolled, CHF in 20 patients was due to CAD and in 16 patients due to DCM. The NYHA class was determined independently by two cardiologists who were blinded to the CPX, echocardiography or scintigraphy results. Sixteen patients were classified as class II and 20 as class III. As a control, 23 patients without cardiopulmonary disease were examined. The CPX was done according to a ramp protocol with continuous measurement of respiratory gases, maximal oxygen consumption (VO2-max) and oxygen consumption at the anaerobic threshold (VO2-AT). A correlation (p = 0.0425) between the NYHA classification and the Weber classification for VO2-AT was found. There was no correlation for VO2-max. VO2-AT was significantly higher in NYHA II patients as compared to NYHA III patients. No significant difference was seen in relation to the VO2-max. In comparison to the normal group, the VO2-AT and VO2-max were significantly lower in NYHA II and III patients. There was no significant correlation between VO2-AT and EF, VO2-max and EF, or between NYHA class and EF. During a 16-month follow-up period lethality was 8/14 patients with VO2-AT < 10 ml/kg/min. Although the NYHA classification provides a valid method for determining the prognosis of CHF patients, if feasible, the CPX examinations should be used to provide updates of the disease progress.

Effects of metoprolol on myocardial beta-adrenoceptors and Gi alpha-proteins in patients with congestive heart failure.

OBJECTIVE: In human heart failure downregulation of beta-adrenoceptors and upregulation of Gi-protein alpha-subunits (Gi alpha) results desensitization of the myocardial beta-adrenergic signal transduction pathway and reduced positive inotropic effects of catecholamines. Metoprolol treatment has been shown to restore the reduced beta-adrenoceptor density in dilated cardiomyopathy. The main objective of the present study was to investigate whether metoprolol also decreases the elevated inhibitory Gi alpha levels in patients suffering from congestive heart failure. METHODS: Total Gi alpha was determined by pertussis toxin-catalysed ADP ribosylation and beta 1- and beta 2-adrenoceptor densities by radioligand binding in right ventricular myocardial biopsies of 18 patients with dilated or ischaemic cardiomyopathy (NYHA II-IV) before and after 3 months of therapy. Nine controls were treated with conventional therapy only [diuretics, digitalis, nitrates, angiotensin-converting enzyme (ACE) inhibitors], and nine received the beta 1-selective blocker metoprolol in addition (mean 98 +/- 12 mg daily). RESULTS: In biopsies from patients treated with metoprolol, Gi alpha significantly decreased to 74% of predrug value and total beta-adrenoceptor increased by a selective increase in beta 1-adrenoceptors (44.7 vs 34.0 fmol mg-1 protein). These effects were accompanied by significantly increased oxygen uptake at the anaerobic threshold (8.65 vs 6.95 ml . kg-1 . min-1). In the control group no significant changes in biochemical and clinical parameters occurred. CONCLUSION: Metoprolol partly reverses Gi alpha-upregulation and beta-adrenoceptor downregulation in heart failure, which might contribute to the clinical improvement of patients treated with beta-blockers.