[Anterior tibialis tendon transfer for the treatment of dynamic supination in patients with clubfoot. Analysis of clinical outcomes and complications]. / Transferencia del tendón tibial anterior para el tratamiento de la supinación dinámica en el pie bot. Análisis de los resultados clínicos y las complicaciones.

INTRODUCTION: our aim was to evaluate the clinical outcomes and complications of anterior tibialis tendon transfer (ATTT) in children with dynamic supination after clubfoot treatment. MATERIAL AND METHODS: children with dynamic supination after initial treatment with Ponseti method or surgery who underwent ATTT between 2008 and 2020 were included for evaluation. Demographic data, previous treatment, associated procedures and fixation method were analyzed. Functional results were evaluated with the grading system described by Thompson. Complications and their treatment were analyzed. RESULTS: a total of 39 patients (57 feet) were analyzed. 70% received previous treatment with Ponseti method, 19.3% underwent surgical posteromedial release, and 10.7% another type of surgical treatment. 88% of cases required associated procedures including Achilles tendon lengthening or tenotomy, plantar fasciotomy, tibial osteotomy, lateral column shortening, posterior release. The predominant type of fixation was the pull-out button method (96.5%). The average follow-up was 31.5 months. According to the Thompson grading system, 52 patients presented good results, two fair and three poor. 98.2% of the feet showed active contraction of the transferred tibialis anterior tendon. There were four complications: plantar irritation, synovial cyst in the dorsum of the foot and deep infection. Two feet required unplanned surgery. CONCLUSION: anterior tibialis tendon transfer is an effective technique to correct residual dynamic supination in patients with clubfoot.

INTRODUCCIÓN: el objetivo de este estudio fue evaluar los resultados clínicos y complicaciones de la transferencia del tendón tibial anterior (TTTA) en niños con pie bot y supinación dinámica. MATERIAL Y MÉTODOS: se incluyeron niños con recurrencia dinámica del pie bot después de tratamiento con método Ponseti o cirugía, que se sometieron a TTTA entre 2008 y 2020. Se analizaron datos demográficos, tratamientos previos, procedimientos asociados y método de fijación. Los resultados funcionales fueron evaluados con el sistema de graduación descrito por Thompson. Se analizaron las complicaciones y su tratamiento. RESULTADOS: se analizaron 39 pacientes (57 pies). Setenta por ciento recibió tratamiento previo con método Ponseti, a 19.3% se le realizó liberación posteromedial y a 10.7% otro tipo de tratamiento quirúrgico. Ochenta y ocho por ciento de los casos requirió procedimientos asociados: tenotomía o alargamiento del tendón de Aquiles, fasciotomía plantar, osteotomía desrotadora de tibia, acortamiento de columna lateral, liberación posterior. El tipo de fijación predominante fue pull-out con botón (96.5%). El seguimiento promedio fue de 31.5 meses. De acuerdo al sistema de Thompson, 52 pacientes presentaron resultados buenos, dos regulares y tres malos. 98.2% de los pies mostraron contracción activa del tendón del tibial anterior transferido. Se presentaron cuatro complicaciones: irritación plantar, quiste sinovial en dorso e infección profunda. Dos pies requirieron cirugía no programada. CONCLUSIÓN: la transferencia del tendón del tibial anterior es una técnica eficaz para corregir la supinación dinámica residual en pacientes con pie bot.

Current trends in the treatment of knee fractures in children and adolescents.

Fractures about the knee are common in children and adolescents. Characteristics of the growing skeleton make children susceptible to specific fractures that do not occur in adults. Understanding the relevant anatomy, pathophysiology, diagnosis, and treatment options are important to decrease the risk of complications. The aim of this article is to discuss the current trends in diagnosis and treatment of tibial eminence, tibial tuberosity sleeve, and osteochondral fractures in children and adolescents.

Las fracturas en el área de la rodilla son frecuentes en los niños y adolescentes. Las características del esqueleto en crecimiento hacen que los niños sean susceptibles de sufrir fracturas específicas que no se producen en los adultos. La comprensión de la anatomía, la fisiopatología, el diagnóstico y las opciones de tratamiento pertinentes son importantes para disminuir el riesgo de complicaciones. El objetivo de este artículo es discutir las tendencias actuales en el diagnóstico y el tratamiento de las fracturas de eminencia tibial, manguito de tuberosidad tibial y osteocondrales en niños y adolescentes.

Current trends in the treatment of knee fractures in children and adolescents / Tendencias actuales en el tratamiento de las fracturas de rodilla en niños y adolescentes

Abstract: Fractures about the knee are common in children and adolescents. Characteristics of the growing skeleton make children susceptible to specific fractures that do not occur in adults. Understanding the relevant anatomy, pathophysiology, diagnosis, and treatment options are important to decrease the risk of complications. The aim of this article is to discuss the current trends in diagnosis and treatment of tibial eminence, tibial tuberosity sleeve, and osteochondral fractures in children and adolescents.

Resumen: Las fracturas en el área de la rodilla son frecuentes en los niños y adolescentes. Las características del esqueleto en crecimiento hacen que los niños sean susceptibles de sufrir fracturas específicas que no se producen en los adultos. La comprensión de la anatomía, la fisiopatología, el diagnóstico y las opciones de tratamiento pertinentes son importantes para disminuir el riesgo de complicaciones. El objetivo de este artículo es discutir las tendencias actuales en el diagnóstico y el tratamiento de las fracturas de eminencia tibial, manguito de tuberosidad tibial y osteocondrales en niños y adolescentes.

Proliferation signal inhibitors and post-transplant malignancies in heart transplantation: practical clinical management questions.

Although malignancy is a major threat to long-term survival of heart transplant (HT) recipients, clear strategies to manage immunosuppression in these patients are lacking. Several lines of evidences support the hypothesis of an anticancer effect of proliferation signal inhibitors (PSIs: mammalian target of rapamycin [mTOR] inhibitors) in HT recipients. This property may arise from PSI's ability to replace immunosuppressive therapies that promote cancer progression, such as calcineurin inhibitors or azathioprine, and/or through their direct biological actions in preventing tumor development and progression. Given the lack of randomized studies specifically exploring these issues in the transplant setting, a collaborative group reviewed current literature and personal clinical experience to reach a consensus aimed to provide practical guidance for the clinical conduct in HT recipients with malignancy, or at high risk of malignancy, with a special focus on advice relevant to potential role of PSIs.

Combined heart and kidney transplantation: long-term analysis of renal function and major adverse events at 20 years.

BACKGROUND: Combined heart-kidney transplantation (HKTx) is an accepted therapeutic option for patients with end-stage heart disease associated with severely impaired renal function. We report our long-term follow-up with this combined procedure. PATIENTS AND METHODS: Between April 1989 to November 2009, nine patients underwent combined simultaneous (HKTx) at our center. Seven patients were males (mean age 45.2 +/- 10.12 years); seven patients were on dialysis at the time of transplantation. RESULTS: Surgical procedures were uneventful in all patients. One patient died in the intensive care unit 41 days after transplantation. During long-term follow-up, three patients died: one due to infection and multiorgan failure 148 months after HKTx, one due to a lung neoplasm after 6 years, and one, a cerebral stroke at 34 months after transplantation. Only one patient experience renal allograft failure secondary to hypertension and cyclosporine nephrotoxicity at 10 years after HKTx with the need for renal replacement therapy. Last estimated glomerular filtration rates of all other patients was 61.3 +/- 17.4 mL/min. CONCLUSIONS: In selected patients, with coexisting end-stage cardiac and renal failure, combined HKTx with an allograft from the same donor proved to give satisfactory short- and long-term results, with a low incidence of both cardiac and renal allograft complications.

Percutaneous coronary interventions in cardiac allograft vasculopathy: a single-center experience.

OBJECTIVE: Cardiac allograft vasculopathy represents an accelerated form of obstructive coronary disease. It is the main cause of late death following heart transplantation. Percutaneous coronary intervention is considered a palliative procedure due to high restenosis rates. The aim of this study was to review our experience with percutaneous coronary interventions using stents in cardiac transplant recipients. METHODS: The present analysis included all primary adult heart transplanted patients who had been discharged from the hospital after transplantation, had a clinical follow-up of 12 months and underwent percutaneous coronary intervention (PCI). RESULTS: Seventy heart transplanted patients underwent percutaneous revascularization. Our analysis comprised 85 first-vessel procedures resulting in treatment of 135 lesions. The mean time from heart transplantation to first intervention was 9.3 +/- 4.8 years. Primary success was obtained in 96% lesions; at least 1 recurrent stenosis event occurred in 16 patients with primarily successful PCI. Lesions treated with drug-eluting stents experienced recurrent stenosis in 16% of cases. During a mean follow-up after PCI of 45.2 +/- 41.7 months, 27 deaths (19 cardiac) and 1 late re-transplantation occurred after PCI. CONCLUSION: In cardiac transplant recipients, percutaneous coronary intervention with stents can be performed safely with high rates of primary success. Restenosis rates were higher compared with coronary interventions in native coronary arteries. Drug-eluting stents seemed to favorably impact restenosis compared with bare-metal stents. The clinical benefit from percutaneous coronary intervention may be reduced due to disease progression in untreated coronary segments.

Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data.

BACKGROUND: Atrial fibrillation is the most common supraventricular arrhythmia in patients with acute myocardial infarction. Recent advances in pharmacological treatment of myocardial infarction may have changed the impact of this arrhythmia. OBJECTIVE: To assess the incidence and prognosis of atrial fibrillation complicating myocardial infarction in a large population of patients receiving optimal treatment, including angiotensin converting enzyme (ACE) inhibitors. METHODS: Data were derived from the GISSI-3 trial, which included 17 944 patients within the first 24 hours after acute myocardial infarction. Atrial fibrillation was recorded during the hospital stay, and follow up visits were planned at six weeks and six months. Survival of the patients at four years was assessed through census offices. RESULTS: The incidence of in-hospital atrial fibrillation or flutter was 7.8%. Atrial fibrillation was associated with indicators of a worse prognosis (age > 70 years, female sex, higher Killip class, previous myocardial infarction, treated hypertension, high systolic blood pressure at entry, insulin dependent diabetes, signs or symptoms of heart failure) and with some adverse clinical events (reinfarction, sustained ventricular tachycardia, ventricular fibrillation). After adjustment for other prognostic factors, atrial fibrillation remained an independent predictor of increased in-hospital mortality: 12.6% v 5%, adjusted relative risk (RR) 1.98, 95% confidence interval (CI) 1.67 to 2.34. Data on long term mortality (four years after acute myocardial infarction) confirmed the persistent negative influence of atrial fibrillation (RR 1.78, 95% CI 1.60 to 1.99). CONCLUSIONS: Atrial fibrillation is an indicator of worse prognosis after acute myocardial infarction, both in the short term and in the long term, even in an unselected population.

Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2).

BACKGROUND: Acute myocardial infarction in younger patients is uncommon, occurring mainly in men. The recent introduction of thrombolysis improved survival, left ventricular function, and infarct size. OBJECTIVE: To evaluate characteristics and clinical outcome of the patients younger than 50 years randomized in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico study. All patients received a thrombolytic treatment. METHODS: The 11483 patients were divided into 3 age subgroups: younger than 50 years (17.2%), between 50 and 70 years (60.2%), and older than 70 years (22.6%). All relations between variables were first determined by an unadjusted analysis. An adjusted analysis was performed by multiple logistic regression models for in-hospital and 6-month mortality. RESULTS: While older patients had a significantly higher rate of a history of hypercholesterolemia, diabetes, and hypertension, smoking and a positive family history were significantly more frequent in younger patients. Total in-hospital and 6-month mortality were significantly lower in patients younger than 50 years (2.7% and 1.2%, respectively) than in patients between 50 and 70 years old (6.9% and 2.7%) and those older than 70 years (21.1% and 8.4%). After multivariate analysis, the predictive value of age was confirmed. CONCLUSIONS: Our findings, based on a large group of patients who received thrombolytic treatment, suggest that younger age is a significant independent indicator of a favorable prognosis after acute myocardial infarction.

Is anticoagulation therapy underused in elderly patients with atrial fibrillation?

Atrial fibrillation (AF) is found in 0.4% of the adult population and is a common condition in the elderly. Its prevalence increases with age to affect 5 to 14% of those over 74 years. Recent evidence indicates that, compared with sinus rhythm, AF is associated with a 4-to 7-fold increase in the risk of stroke. However, there is strong evidence from randomised trials that full anticoagulation with warfarin substantially reduces the risk of stroke. Elderly patients are among those at higher risk and stand to gain the most from such treatment. They are also at higher risk for complications related to anticoagulant therapy and this sometimes makes clinical decisions difficult. There is a strong rationale for prescribing warfarin for all patients with AF who are over 65 years and free of contraindications. Some concerns exist about the benefit: risk ratio of warfarin in patients aged > 75 years. The answer is probably to use low intensity anticoagulant therapy (international normalised ratio 2.0 to 3.0), which is safer but no less effective than higher intensity regimens. Few data are available in the literature on physicians' attitudes to anticoagulation in elderly patients with AF. Although the results of randomised clinical trials in AF seem to suggest that anticoagulants and/or aspirin (acetylsalicylic acid) are underused in the elderly, over 90% of the patients initially screened were excluded from randomisation, making the sample highly selected. Compared with randomised controlled trials, some observational studies seem to indicate a higher likelihood of using anticoagulation and have targeted the intensity of anticoagulation according to age and clinical scenario.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 1: Clinical data.

There is an increasing body of clinical trial evidence to support the use of angiotensin-converting enzyme (ACE) inhibitors in the management of patients following myocardial infarction (MI). Enthusiasm for the use of ACE inhibitors in the acute phase of MI had previously been tempered by the adverse results of an early trial. However, exciting new information is available from several large, randomized studies that has not only quelled those initial concerns but also attests to the efficacy of using this class of medication in the first 24 h after an acute MI. A Canadian National Opinion Leader Symposium was held in November 1995 to review the results of the major ACE inhibitor clinical trials and to discuss key issues and controversies surrounding their use in acute MI. The focus of this paper, the first of two parts, is on the results of the major ACE inhibitor clinical trials.

Angiotensin-converting enzyme inhibition in myocardial infarction--Part 2: Clinical issues and controversies.

Over the past 10 years, several clinical studies have concluded that, in patients already receiving conventional therapies, angiotensin-converting enzyme (ACE) inhibitors further reduce the risk of death following myocardial infarction (MI). Post-MI ACE inhibitors have proven to be effective as long term therapy in high risk patients as well as when used for much shorter periods in a broad patient population. However, while considerable mortality data have been collected, the effects of ACE inhibitors post-MI on other cardiovascular outcomes have not been as well documented. In addition, a number of issues regarding the most effective use of these agents remain unresolved. This paper, the second of two parts, focuses on the clinical issues and controversies surrounding the use of ACE inhibitors following acute MI. The effects of ACE inhibitors on the outcomes of sudden death, nonsudden death, recurrent angina, mitral regurgitation and left ventricular dysfunction are reviewed and potential mechanisms of action are proposed. In addition, ACE inhibitor therapy is discussed in terms of patient selection criteria, choice of agent, optimal dosing regimen, concomitant use of other therapies and relative costs of treatment. Finally, potential mechanisms of action of ACE inhibitors are proposed for each of the outcomes examined.

Prognostic significance of maximal exercise testing after myocardial infarction treated with thrombolytic agents: the GISSI-2 data-base. Gruppo Italiano per lo Studio della Sopravvivenza Nell'Infarto.

Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over the past decade acute myocardial infarction treatment has changed because of new thrombolytic therapies and consequently, the value of exercise testing is under debate. The GISSI-2 database allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 patients, on average 28 days after randomisation. The test was not performed in 3923 patients because of contraindications. The test was judged positive for residual ischaemia in 26% of the patients, negative in 38%, and non-diagnostic in 36%. Among the patients with a positive stress test result, 33% had symptoms, whereas 67% had silent myocardial ischaemia. The mortality rate was 7.1% among patients who did not have an exercise test and 1.7% [correction of 7.1%] for those with a positive test, 0.9% for those who had a negative test, and 1.3% for those who did not have a diagnostic test. In the adjusted analysis, symptomatic induced ischaemia, submaximal positive result, low work capacity, and abnormal systolic blood pressure were independent predictors of 6-month mortality (relative risks [RR] 2.54, 95% CI 1.27-5.08, 2.28, 1.17-4.45, 2.05, 1.23-3.42, and 1.86, 1.05-3.31, respectively). However, when these factors were tested simultaneously, only symptomatic induced ischaemia and low work capacity were confirmed as independent predictors of mortality (RR Cox 2.07, 95% CI 1.02-4.23 and 1.78, 1.06-2.99, respectively). Patients with a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation should be devoted to the patients who cannot undergo exercise testing, because the potential to influence outcome appears to be much greater.

Thrombolytic therapy in selected patients with impending myocardial reinfarction.

BACKGROUND: In selected patients with postinfarction angina and impending reinfarction, thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) or streptokinase is highly effective in avoiding a new myocardial infarction. METHODS: To avoid major cardiac events, we treated 14 consecutive patients with thrombolytic therapy because of impending reinfarction with ECG ST-segment elevation. Thirteen patients received rt-PA (100 mg over 3 hours), and one patient received streptokinase (1.5 million IU over 1 hour). All patients had failed to respond to maximal medical therapy with intravenous nitrates, beta-blockers, Ca-antagonists, heparin, and opiates. RESULTS: In all patients, clinical and ECG signs of acute ischemia resolved completely within 1 hour after beginning thrombolysis, and no patient developed biochemical markers of myocardial infarction. Ten patients underwent coronary angiography: five had three-vessel disease, two had two-vessel disease, and three had one-vessel disease. The culprit lesion was located in the left anterior descending artery in eight cases and the right coronary artery in two. No patient showed intracoronary thrombus. Four patients underwent successful, semiurgent percutaneous transluminal coronary angioplasty; three received an elective and two an urgent coronary artery bypass graft. CONCLUSIONS: Thrombolysis (or repeated thrombolysis) is effective in selected patients with clinical ECG signs of impending reinfarction. It can temporarily stabilize the condition of many patients, thus allowing safer mechanical revascularization to be performed.

[Sepsis and endocarditis: two rare complications following pacemaker implantation. Description of a case and review of the literature]. / Sepsi ed endocardite: due rare complicanze conseguenti all'impianto di pacemaker. Descrizione di un caso e revisione della letteratura.

A case of Staphylococcus aureus tricuspid valve endocarditis in a patient with permanent transvenous VVI pacemaker and recurrent febrile episodes is described. Medical treatment was not effective, and only with surgical removal of the lead was the infection successfully treated.

GISSI trials in acute myocardial infarction. Rationale, design, and results.

The first Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto (GISSI) study showed striking evidence of the effectiveness and safety of intravenous thrombolytic treatment in acute myocardial infarction (MI). Since publication in The Lancet, the original report has become a reference work for every paper which deals with thrombolysis. In addition to GISSI's scientific value, these studies applied formal research to routine clinical practice outside of referral centers. Nearly all Italian CCUs took part in the GISSI projects, so that the results provide a profile of the patient who seeks care for acute MI in Italy. This wide data base allowed GISSI investigators to look into some relevant clinical events, eg, primary ventricular fibrillation, stroke, and in-hospital reinfarction. The GISSI-2 trial followed the GISSI-1 philosophy. The package of treatments recommended after extensive discussion with all the investigators (beta-blocker, aspirin, nitrates) was widely adopted. Now, only five years after the start of the GISSI-1, the overall mortality of Italian patients with acute MI has decreased from 13.0 percent to about 9 percent, and the number of patients with acute MI arriving in hospital within 1 h of the onset of symptoms has increased 50 percent. It is the wish of the GISSI investigators that this approach to treating acute MI will be regarded and acknowledged as their major contribution to the problem.

[Tissue-type plasminogen activator (t-PA): comments on results of the GISSI-2 study]. / Attivatore tessutale del plasminogeno (t-PA): commento sui risultati del GISSI-2.

12,490 patients from the GISSI-2 trial were randomly allocated to alteplase (recombinant tissue-type plasminogen activator, t-PA) or streptokinase (SK) and beginning 12 hours after the start of thrombolytic therapy to subcutaneous heparin or no heparin. No significant differences in hospital mortality were found between the two thrombolytic treatments as well as between heparin and no heparin administration. The incidence of major cardiac complications was also very similar in the different groups. The incidence of major bleedings was significantly higher in SK and heparin treated patients, whereas the overall incidence of stroke was similar in all groups. SK and t-PA with or without post-thrombolytic heparin treatment appear equally effective and safe for use in routine conditions care, in all patients with acute myocardial infarction (AMI).