Use of intravascular ultrasound to compare effects of different strategies of lipid-lowering therapy on plaque volume and composition in patients with coronary artery disease.
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BACKGROUND: We studied whether lipid-lowering therapy with atorvastatin (target LDL cholesterol [LDL-C] <100 mg/dL) compared with a moderate treatment regimen that used other lipid-lowering drugs led to a lesser progression of atherosclerosis and to different changes in plaque echogenicity in patients with coronary artery disease. METHODS AND RESULTS: This study was a 12-month, open-label, randomized, multicenter trial, which used serial 3D intracoronary ultrasound to calculate plaque volume and plaque echogenicity. After transcatheter therapy, 131 patients were randomized (atorvastatin n=65, usual care n=66). The target plaque had to be a minor lesion (ie, a diameter stenosis of <50% on angiography). After 12 months, mean LDL-C was reduced from 155 to 86 mg/dL in the atorvastatin group and from 166 to 140 mg/dL in the usual care group. Mean absolute plaque volume showed a larger increase in the usual care group compared with the atorvastatin group (usual care 9.6+/-28.1 mm(3), atorvastatin 1.2+/-30.4 mm(3); P=0.191). The hyperechogenicity index of the plaque increased to a larger extent for the atorvastatin group than for the usual care group, with a significant treatment effect for the percent change (atorvastatin 42.2%, usual care 10.1%; P=0.021). CONCLUSIONS: One year of lipid-lowering therapy to <100 mg/dL LDL-C most likely led to a slowdown of plaque growth of minor lesions. The significantly larger increase in plaque hyperechogenicity is most likely due to a change in plaque composition. (+info)
Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain.
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INTRODUCTION: A structured and rigorous methodology was developed for the formulation of evidence-based clinical practice guidelines (EBCPGs), then was used to develop EBCPGs for selected rehabilitation interventions for the management of knee pain. METHODS: Evidence from randomized controlled trials (RCTs) and observational studies were identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. Meta-analysis was conducted where possible. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. DEVELOPING RECOMMENDATIONS: An expert panel was formed by inviting stakeholder professional organizations to nominate a representative. This panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The panel decided that evidence of clinically important benefit (defined as 15% greater relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance was also required but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, function, patient global assessment, quality of life, and return to work, providing that these outcomes were assessed with a scale for which measurement reliability and validity have been established. VALIDATING THE RECOMMENDATIONS: A feedback survey questionnaire was sent to 324 practitioners from 6 professional organizations. The response rate was 51%. RESULTS: Two positive recommendations of clinical benefit were developed: (1) transcutaneous electrical nerve stimulation (TENS) and therapeutic exercises were beneficial for knee osteoarthritis, and (2) there was good agreement with these recommendations from practitioners (73% for TENS, 98% for exercises). For several interventions and indications (eg, thermotherapy, therapeutic ultrasound, massage, electrical stimulation), there was a lack of evidence regarding efficacy. CONCLUSIONS: This methodology of developing EBCPGs provides a structured approach to assessing the literature and developing EBCPGs that incorporates clinicians' feedback and is widely acceptable to practicing clinicians. Further well-designed RCTs are warranted regarding the use of several interventions for patients with knee pain where evidence was insufficient to make recommendations. (+info)
While cardiovascular disease develops in up to 50% of adult patients with ankylosing spondylitis, it is very uncommon in its juvenile counterpart. Regarding the early stage of the disease, before onset of sacroiliac joint changes, only two cases with aortic incompetence have been published while reports of mitral valve involvement are not available. A 13 year old boy is described with an HLA-B27 positive asymmetric oligoarthritis and enthesitis, without back pain or radiographic evidence of sacroiliitis. Echocardiography showed an echogenic structure measuring 8 x 11 x 20 mm at the fibrous continuity between the aortic and mitral valves extending through a false tendon into an echogenic thickened posterior papillary muscle, causing a grade II aortic and grade I/II mitral regurgitation. Short term corticosteroid and long term non-steroidal anti-inflammatory drug and disease modifying antirheumatic drug treatments efficiently controlled the symptoms. The cardiac findings remained unchanged during a follow up of 20 months. Careful cardiac evaluation appears to be mandatory even in these young patients. (+info)
Propensity for osteoarthritis and lower limb joint pain in retired professional soccer players.
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OBJECTIVE: To quantify the prevalence of osteoarthritis and the severity of pain in the lower limb joints of players retired from English professional soccer. METHOD: An anonymous self administered questionnaire was distributed to 500 former players registered with the English Professional Footballers' Association. The questionnaire was designed to gather information on personal details, physical activity loading patterns, history of lower limb joint injury, and current medical condition of the lower limb joints. RESULTS: Of 500 questionnaires distributed, 185 (37%) were returned. Nearly half of the respondents (79: 47%) retired because of injury; 42% (33) were acute injuries and 58% (46) chronic injuries. Most of the acute injuries that led to early retirement were of the knee (15: 46%), followed by the ankle (7: 21%) and lower back (5: 15%). Most of the chronic injuries that led to early retirement were also of the knee (17: 37%), followed by the lower back (10: 22%) and the hip (4: 9%). Of all respondents, 32% (59) had been medically diagnosed with osteoarthritis in at least one of the lower limb joints. More respondents had been diagnosed with osteoarthritis in the knee joints than either the ankle or the hip joints. Significantly (p<0.001) more respondents reported pain in one lower extremity joint during one or more daily activities than those who did not (joint pain: 137, 80%; no joint pain: 35, 20%). CONCLUSION: The risk for professional soccer players of osteoarthritis in at least one of the lower extremity joints is very high and significantly greater than for the general population. The results support the suggestion that professional soccer players should be provided with health surveillance during their playing career. (+info)
Vertical-split fracture of mandibular condyle and its sequelae.
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A case of vertical-split fracture of the right mandibular condyle and its sequelae is presented. The patient was a 16-year-old female being assessed for orthodontic treatment. Orthopantomograph and plain joint view radiographs showed a remodelled condyle which had suffered trauma 10 years previously. This type of fracture is unusual in nature but has not led to any secondary lack of growth, restriction of movement or facial asymmetry. (+info)
Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial.
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BACKGROUND: The purpose of this study was to compare the efficacy of electroacupuncture (EA), diclofenac and their combination in symptomatic treatment of osteoarthritis (OA) of the knee. METHODS: This study was a randomized, single-blind, placebo controlled trial. The 193 out-patients with OA of the knee were randomized into four groups: placebo, diclofenac, EA and combined (diclofenac plus EA). Paracetamol tablets were prescribed as a rescue analgesic during the study. The patients were evaluated after a run-in period of one week (week 0) and again at the end of the study (week 4). The clinical assessments included the amount of paracetamol taken/week, visual analog scale (VAS), Western Ontario and McMaster Universities (WOMAC) OA Index, Lequesne's functional index, 50 feet-walk time, and the orthopedist's and patient's opinion of change. RESULTS: One hundred and eighty six patients completed the study. The improvement of symptoms (reduction in mean changes) in most outcome parameters was greatest in the EA group. The proportions of responders and patients with an overall opinion of "much better" were also greatest in the EA group. The improvement in VAS was significantly different between the EA and placebo group as well as the EA and diclofenac group. The improvement in Lequesne's functional index also differed significantly between the EA and placebo group. In addition, there was a significant improvement in WOMAC pain index between the combined and placebo group. CONCLUSION: EA is significantly more effective than placebo and diclofenac in the symptomatic treatment of OA of the knee in some circumstances. However, the combination of EA and diclofenac treatment was no more effective than EA treatment alone. (+info)
A six-month randomized, controlled, double-blind, dose-response comparison of intravenous pamidronate (60 mg versus 10 mg) in the treatment of nonsteroidal antiinflammatory drug-refractory ankylosing spondylitis.
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OBJECTIVE: To determine the safety and efficacy of intravenous (IV) pamidronate treatment in ankylosing spondylitis (AS) patients who have had a suboptimal response to nonsteroidal antiinflammatory drugs (NSAIDs). METHODS: Pamidronate at 60 mg was compared with pamidronate at 10 mg rather than placebo in view of the high incidence of transient arthralgias upon first IV exposure to the drug. The drug were given monthly for 6 months in a randomized double-blind, controlled trial. The inclusion criterion was active disease (Bath AS Disease Activity Index [BASDAI] of > or = 4 or morning stiffness of > or = 45 minutes) despite stable NSAID therapy. The primary outcome measure was the BASDAI, and secondary outcomes included the Bath AS Functional Index (BASFI), Bath AS Global Index (BASGI), Bath AS Metrology Index (BASMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and percentage of patients achieving a reduction of > or = 25% in the BASDAI. Outcome assessments were done at -2, 0, 12, and 24 weeks, and analysis was by intent to treat. RESULTS: Eighty-four AS patients (67 men and 17 women; mean age 39.6 years and mean disease duration 15.1 years) were enrolled. Dosage groups were well matched at baseline for demographics, disease activity, and functional indices. At 6 months, the mean BASDAI had decreased by 2.22 (34.5%) in the 60-mg group and by 0.93 (15%) in the 10-mg group (P = 0.002). Significantly greater reductions in the 60-mg group were also noted for the BASFI (P < 0.001), BASGI (P = 0.01), and BASMI (P = 0.03). Significantly more patients achieved a reduction of > or = 25% in the BASDAI in the 60-mg group versus the 10-mg group (63.4% versus 30.2%; P = 0.004). Differences in ESR/CRP were not significant (NS). Withdrawals included 9 (20.9%) from the 10-mg group and 3 (7.3%) from the 60-mg group (P NS). Adverse events were confined to transient arthralgias/myalgias after the first IV infusion, occurring in 68.3% and 46.5% of patients in the 60-mg and 10-mg groups, respectively (P NS). CONCLUSION: Pamidronate has dose-dependent therapeutic properties in AS. (+info)
A new acute inflammatory syndrome related to the introduction of mycophenolate mofetil in patients with Wegener's granulomatosis.
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Mycophenolate mofetil (MMF) is increasingly used for prevention of allograft rejection and to treat immune disorders. We report the development of an acute inflammatory syndrome in two patients with Wegener's granulomatosis after MMF was introduced, because of persistent renal and systemic disease activity despite cyclophosphamide treatment. Within 1 week both patients developed an acute inflammatory syndrome, characterized by fever, arthralgias and muscle pain. No infection could be detected and no indications for increased Wegener's activity were present. MMF was stopped resulting in a rapid and complete resolution of the syndrome. A rechallenge with 2 g of MMF in the second patient resulted in a relapse of the syndrome within 4 days. There was an association between symptoms and increased levels of mycophenolic acid (MPA) acyl glucuronide and serum interleukin-6, suggesting the induction of inflammatory cytokines by MPA acyl glucuronide as the cause of the syndrome. Therefore, special attention should be given to side effects such as fever, arthralgias and muscle pain when treating patients with Wegener's granulomatosis during the active phase. Because this side effect of MMF may also occur after solid organ transplantation and in other immune disorders, pharmacokinetic profiling of MPA and MPA acyl glucuronide is needed in future studies with MMF. (+info)