Influence of updated guidelines on short- and long-term mortality in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

AIM: In 2002 the ACC/AHA guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) were updated. We aimed to answer whether the implementation of updated guidelines was capable of influencing short- and long-term mortality in these patients. METHODS: We analyzed data on 812 consecutive patients who were admitted with either UA or NSTEMI between 2001 and 2004. Patients admitted in the two years before the implementation of updated guidelines (UA(01/02) group and NSTEMI(01/02) group) were compared to patients admitted in the two years thereafter (UA(03/04) group and NSTEMI(03/04) group). Yearly follow-up concerning all-cause mortality was obtained up to four years. RESULTS: The rate of revascularizations, the percentage of procedures performed within 48 h of admission, and the administration of clopidogrel increased significantly. However, still many - especially high-risk - patients did not receive revascularization. Patients of both UA groups had an identical in-hospital mortality rate. Differences in mortality between groups gained statistical significance over time (four-year mortality; 15.1% for the UA(03/04) group vs. 26.5% for the UA(01/02) group, p=0.014; HR 0.49 95% CI 0.28-0.87). In patients with NSTEMI in-hospital mortality decreased from 18.4% in the NSTEMI(01/02) group to 9.6% in the NSTEMI(03/04) group (p=0.011; HR 0.47 95% CI 0.26-0.84), and 1-year mortality from 34.7% to 25.1% (p=0.038; HR 0.63 95% CI 0.41-0.98), respectively. Mortality rates beyond one year were still lower in the NSTEMI(03/04) group as compared to the NSTEMI(01/02) group but it did not reach statistical significance. Multivariate Cox-regression analysis revealed furthermore that also patients with higher age and/or renal dysfunction benefit from an early invasive strategy. CONCLUSION: The implementation of updated guidelines for NSTE-ACS had significant impact on short- and long-term mortality. However, an early invasive strategy is still withheld to a significant number of high-risk patients, who would benefit from an invasive treatment.

[Shoulder joint disorder: correlation of findings by arthroscopy and magnetic resonance imaging]. / Korelace patologických nálezu ramenního kloubu pomocí artroskopie versus nukleární magnetickou rezonancí

PURPOSE OF THE STUDY: To evaluate the efficacy of magnetic resonance (MR) examination in intra- and extra- articular shoulder disorders, in comparison with arthroscopic findings, in patients with both acute injuries and chronic problems of the shoulder. MATERIAL AND METHODS: Conventional MR images and MR arthrograms of the shoulder were obtained in 35 patients treated between January 2004 and January 2006. Each MR image was evaluated by five radiologists experienced in assessing findings on the musculoskeletal system. Subsequently, the patients underwent shoulder arthroscopy performed by shoulder arthroscopy surgeons. Each detailed arthroscopic report was compared with the pre-operative MR findings, and the sensitivity and specificity of MR examination were calculated. The arthroscopic findings served as standards of reference for comparison. RESULTS: SLAP lesions were found intra-operatively in seven out of the 35 patients (20 %). MR sensitivity was 43 % (3 to 7 patients) and specificity was 96 % (27 to 28). The accuracy of MR for SLAP lesion diagnosis was 86 % (30 of 35 patients). Tears in the anterior labrum were diagnosed by arthroscopy in 16 of 35 patients (46 %); MR sensitivity was 44 % (7 of 16 patients) and specificity was 89 % (17 of 19). The accuracy of MR for diagnosing labral tears was 68 % (24 of 35 patients). DISCUSSION: When designing our study, we tried to avoid limitations of similar investigations. We employed a nuclear magnetic resonance system with high resolution and standardized both the arthroscopic technique and the evaluation of MR images. Our results of diagnosing rotator cuff disorders and SLAP lesions are in agreement with those of other relevant studies. The limitation of our study was a small size of the group. CONCLUSIONS: Although MR imaging is a sensitive method suitable for diagnosing some shoulder disorders, the MR imaging of SLAP lesions and labral tears does not give results accurate enough to be used for pre-operative planning.

[Arthroscopy of the knee joint in childhood]. / Artroskopie kolenního kloubu u pacientu detského veku v nasem souboru.

PURPOSE OF THE STUDY: Arthroscopy is generally regarded as a method suitable exclusively for the treatment of adult patients and only occasionally used in children as a diagnostic tool. Since the number of arthroscopic procedures has considerably increased in recent years, we decided to evaluate the knee arthroscopies performed in pediatric patients, focusing on a correlation between the preoperative diagnosis and arthroscopic findings. MATERIAL AND METHODS: The clinical records on 319 arthroscopic procedures in 311 children treated at our Department between 1995 and 2002 were retrospectively analyzed. The procedures were evaluated in view of the diagnosis established before surgery and that confirmed by arthroscopy. The patients were placed in two groups: preadolescents (younger than 13 years) and adolescents (13 to 18 years old). All patients were treated by the standard arthroscopic procedure. Except for two patients, all children underwent elective surgery of diagnostic or therapeutic reasons. RESULTS: Mediopatelar plica was the most frequent pathology and was treated in 26% of the patients. Meniscus lesions were found in 35% of all patients, but were more frequent in the adolescent group, in which two thirds of all patients were treated for this condition. The crucial ligaments were affected in 10% of all patients. In 52 patients, no pathology was found on arthroscopic examination. There was no difference in findings between the two groups. DISCUSSION: In some patients, the arthroscopic findings differed from the diagnosis established preoperatively, with the pathological condition being misdiagnosed more often in the adolescent group. The correct diagnosis was confirmed in 81.4%. The findings were negative in 16.4% of the patients, which is in agreement with the literature data. CONCLUSIONS: Based on our experience we conclude that great caution be exercised when making the preoperative diagnosis. The expertise of the diagnosing physician and availability of feedback are emphasized.

Spontaneous and interferon-induced natural cytotoxicity in Crohn's disease.

Natural killer cell (NK) activity and antibody-dependent cellular cytotoxicity (ADCC) exerted by peripheral blood mononuclear cells (PMNC) were investigated in 53 patients with Crohn's disease (CD). NK activity and ADCC were found to be significantly reduced in patients with CD (p less than 0.0005) as compared to healthy controls. Both effector cell functions increased after in vitro treatment of PMNC with gamma-interferon, but did not reach the levels found in controls (p less than 0.0005). Neither NK activity nor ADCC was significantly influenced by therapy with corticosteroids. Moreover, the reduced serum zinc levels in patients with CD, which have been shown to be associated with impaired immune function, did not influence the lytic effector cell mechanism assayed either. Finally, no association could be found between NK cell activity or ADCC and CD activity index, the extent of the disease and several laboratory parameters of inflammation. We conclude that patients with CD have a reduced lytic effector cell function which remains uninfluenced by corticosteroid treatment and seems to be present independently of disease activity.