Validation of two echocardiographic indexes to improve the diagnosis of complex coarctations.

OBJECTIVES: Coarctation of the aorta is one of the most common congenital heart defects. Its diagnosis may be difficult in the presence of a patent ductus arteriosus, of other complex defects or of a poor echocardiographic window. We sought to demonstrate that the carotid-subclavian artery index (CSA index) and the isthmus-descending aorta ratio (I/D ratio), two recently described echocardiographic indexes, are effective in detection of isolated and complex aortic coarctations in children younger and older than 3 months of age. The CSA index is the ratio of the distal aortic arch diameter to the distance between the left carotid artery and the left subclavian artery. It is highly suggestive of a coarctation when it is <1.5. The I/D ratio defined as the diameter of the isthmus to the diameter of the descending aorta, suggests an aortic coarctation when it is less than 0.64. METHODS: This is a retrospective cohort study in a tertiary care children's hospital. Review of all echocardiograms in children aged 0-18 years with a diagnosis of coarctation seen at the author's institution between 1996 and 2006. An age- and sex-matched control group without coarctation was constituted. Offline echocardiographic measurements of the aortic arch were performed in order to calculate the CSA index and I/D ratio. RESULTS: Sixty-eight patients were included in the coarctation group, 24 in the control group. Patients with coarctation had a significantly lower CSA index (0.84+/-0.39 vs 2.65+/-0.82, p<0.0001) and I/D ratio (0.58+/-0.18 vs 0.98+/-0.19, p<0.0001) than patients in the control group. Associated cardiac defects and age of the child did not significantly alter the CSA index or the I/D ratio. CONCLUSIONS: A CSA index less than 1.5 is highly suggestive of coarctation independent of age and of the presence of other cardiac defects. I/D ratio alone is less specific than CSA alone at any age and for any associated cardiac lesion. The association of both indexes improves sensitivity and permits diagnosis of coarctation in all patients based solely on a bedside echocardiographic measurement.

Avulsion fracture of peroneus longus tendon at the first metatarsal insertion: a case report : P16

Introduction: Isolated avulsion fracture at the plantar lateral base of the first metatarsal (M1) is very rare. Case report: A 35 year old overweight woman sustained an eversion strain of her right foot. Despite pain along M1 she was able to continue walking for three days before presenting to her family doctor. Swelling on the plantar aspect of the foot was noticed, there was also pain at eversion of the foot and extension of the ankle. Plain X-ray showed no abnormalities. A MRI showed minimal bone bruise at the basis of M1 and a partial rupture of the peroneus longus tendon at its insertion. The patient was allowed to walk with partial weight bearing with a soft ankle brace. After 6 months she presented at our hospital because of persistent pain. There was still a painful insertion of the peroneus longus but active plantarflexion of M1 was possible. Plain X-rays were poorly contributive except for a discrete flattening of the longitunal arch. CT-scan showed a non displaced fracture at the M1-basis. A protocol with partial weight-bearing in a short-leg cast and partial weight-bearing orthosis each for 6 weeks was unsuccessfully attempted. Therefore, an excision of the non healed bone fragment at the basis of M1 and a first tarsometatarsal joint arthrodesis were performed. Postoperatively the patient wore a partial weight-bearing short leg cast for 6 weeks followed by a weight-bearing short leg cast for 6 weeks with favourable outcome. Discussion: Initial internal fixation has been reported to lead to good results [1, 2]. In our case the conservative treatment failed and leaded to non union. At that time we considered as too risky (overweight) to excise the fragment and reattach the peroneus longus tendon. Therefore, we excised the fragment and fused the first tarsometatarsal joint. This procedure allowed, at least partially, to compensate for the function of the peroneus longus tendon. 1 Murakami T, et al. Avulsion fracture of the peroneus longus at the first metatarsal insertion: a case report. Br J Sports Med. 2004. 2 Kwak HY, and Bae SW. Isolated avulsion fracture at the plantar lateral base of the first metatarsal: a case report. Foot Ankle Int 2000.

Diagnosis and management of blunt great vessel trauma.

Traditionally, thoracic aortic rupture, suspected after blunt thoracic trauma, is characterized by a chest radiograph showing a widened mediastinum. The diagnostic machinery consecutively activated still depends heavily on the pressure as additional traumatic lesions. A patient with additional cranio-cerebral trauma would typically undergo contrast-enhanced computed tomography or magnetic resonance imaging of head, chest, and other regions. In a number of patients these analyses would confirm the presence of blood in the mediastinum without formal proof of an aortic disruption. This is because mediastinal hematomas may be caused not only by an aortic rupture, but also by numerous other blood sources including fractures of the spine and other macro- and microvascular lesions providing similar images. Therefore, aortic angiography became our preferred diagnostic tool to identify or rule out acute traumatic lesions of not only the aorta but with great vessels. However recently, a number of traumatic aortic transsections have been identified by transoesophageal echocardiography (TEE). TEE has the additional advantage of being a bed-side procedure providing additional information about cardiac function. The latter analysis allows for identification and quantification of cardiac contusions, post-traumatic myocardial infarctions, and valvar lesions which are of prime importance to develop an adequate surgical strategy and to assess the risk of the numerous emergency procedures required in patients with polytrauma. The standard approach for repair of isthmic aortic rupture is through a lateral thoracotomy. Distal and proximal control of the aorta can be achieved in a substantial number of cases before complete aortic rupture occurs and a higher proportion of direct suture repair can be achieved under such circumstances. Most proximal descending aortic procedures are performed without cardiopulmonary bypass (clamp and go) but paraplegia may occur before, during, or after the procedure. Ascending aortic lesions and disruption of the aortic arch, the supra-aortic vessels, the main pulmonary arteries, the great veins as well as cardiac lesions are best approached through a sternotomy, which may have to be extended. Cardiopulmonary bypass allowing for deep hypothermia and circulatory arrest is often required and carries its own complications. It is not clear whether the increasing proportion of ascending aortic and cardiac lesions which are observed nowadays are due to a change in trauma mechanics (i.e., speed limits, seat belts, air-bags), an improvement of the diagnostic tools or both.

Evaluation et validation des équations de prédiction du risque de diabète dans la population lausannoise : étude CoLaus

Le diabète de type 2 est une maladie fréquente et en augmentation dans le monde entier. Malheureusement, elle est souvent diagnostiquée à un stade ou des complications sont déjà apparues. Depuis quelques années, des scores ont été développés pour identifier les sujets à risque de développer cette maladie. L'utilisation d'un tel score par le praticien pourrait amener ces patients à des mesures préventives, telles que le changement d'hygiène de vie, ou la prescription d'un traitement médicamenteux. Le but de notre étude est de comparer et de valider différents scores de risques de diabète de type 2 et de déterminer leur capacité à prédire la survenue de cette maladie dans la population de la cohorte CoLaus. Les premiers résultats, en étude transversale, ont tout d'abord montré de grandes différences quant à la population à risque d'un score à l'autre. En effet, le nombre de personnes à traiter varie considérablement selon la méthode utilisée. Ces différents scores ont donc nécessité une validation prospective. Ces résultats ont fait l'objet d'une publication (Schmid et col, Diabetes Care. 2011 Aug;34(8):1863-8). Au moyen des données du suivi à 5 ans, il est sorti qu'un score de risque utilisant des variables biologiques et cliniques, ainsi qu'un score utilisant des variables uniquement cliniques, obtenaient de très bon résultats quant à la prédiction du diabète de type 2. En effet, un des scores testés donne une valeur prédictive positive d'environ 20% à 5 ans, ce qui signifie qu'un patient « détecté » sur 5 pourrait bénéficier d'une intervention précoce. Toutefois, ces résultats concernent la population lausannoise et ne sont donc pas forcément applicables à l'ensemble de la population suisse. De plus, de plus amples études sont nécessaires évaluer l'efficacité d'un tel score dans la prévention du diabète en Suisse. Ces résultats ont fait l'objet d'une seconde publication (Schmid et col, Arch Intern Med. 2012 Jan 23;172(2):188-9). Dans un troisième volet de l'étude, l'impact de marqueurs génétiques a été évalué dans un sous- groupe de la population CoLaus. Les résultats n'ont toutefois montré qu'une très faible amélioration de la prédiction du risque en utilisant ces marqueurs. Ceci devrait nous encourager à intensifier les efforts de prévention sur le style de vie pour toute la population, plutôt qu'une approche ciblée sur les personnes génétiquement prédisposées. Ces résultats ont fait l'objet d'une troisième publication (Schmid et col, J Clin Endocrinol Metab. 2012 Apr 24. [Epub ahead of print]). La même démarche méthodologique a été utilisée pour évaluer l'importance pronostique de plusieurs marqueurs inflammatoires (interleukines 1 et 6, Τ Ν F-, protéine C-réactive) hépatiques (GT) ou adipocytaires (leptine et adiponectine) dans la survenue du diabète. Ces résultats sont actuellement soumis au Journal of Clinical Endocrinology and Metabolism).

Entre rabbis et brahmanes : exercices de comparaison

(Résumé de l'ouvrage) L'histoire des religions autant dans ses procédés que dans ses concepts est fondée sur la comparaison. Tels le mythe, le sacrifice, l'initiation ou la purification, ces concepts comparatifs ont fini par être neutralisés dans une ontologie à prétention universelle. Des religions on en est revenu à la religion, pour le plus grand profit des théologiens chrétiens, protestants et catholiques, qui y ont trouvé une nouvelle légitimité académique. Raison supplémentaire pour revenir sur les démarches comparatives et pour en critiquer les effets totalisants : la comparaison s'impose comme méthode à condition d'être contrastive et différentielle. Elle induit un regard relativisant et décentré ; ce regard oblique d'une part rend justice aux spécificités des manifestations et pratiques religieuses décrites dans leur diversité ; d'autre part il est la condition même, en sciences humaines en général, d'une position critique, antidote indispensable aux replis disciplinaires et institutionnels de nos contemporains. Les contributions réunies ici à la suite d'une journée d'échange passée à comparer les démarches comparatives en histoire des religions entraînent lectrices et lecteurs des rites du polythéisme grec aux pratiques contemporaines du yoga, en passant par différentes prétentions universalisantes du monothéisme chrétien, par les pratiques de l'hospitalité en régime rabbinique et en hindouisme brahmanique, mais aussi par la question du salut individuel en philosophie néoplatonicien, ne ou en théologie augustinienne, par les gestes de la prière dans les religions amérindiennes et dans la mystique chrétienne ou par les prophétismes chrétien et musulman ; ceci par le biais de méthodes comparatives se fondant sur une démarche historique, structurale, discursive ou cognitive.

Initial experience with hybrid surgery in congenital heart disease in a single center : P171

Introduction: A hybrid intervention is a joint procedure involving the interventional cardiologist and the cardiac surgeon. At our institution we have opted for this type of approach in congenital heart disease since 2005. We report here our initial experience. Cases: 1. A 3 year old boy with double aortic arch and multiple muscular ventricular septal defects (VSD),was readdressed for pulmonary band (PAB) removal and residual VSD closure after previous palliation. After surgical removal of the PAB, the surgeon provided a minimal transventricular access for placement of a 6mm Amplatzer® muscular VSD occluder by the cardiologist under transoesophageal guidance. The patient was extubated the same day and discharged after 5 days. 2. An 8 year old girl with Williams syndrome was followed for two large VSDs and severe peripheral pulmonary arteries (PA) stenosis. The membranous VSD was closed surgically, the muscular VSD during the same operation by direct placement of a 12 mm Amplatzer® muscular VSD occluder. During rewarming, balloon angioplasty of peripheral PA stenosis was achieved under fluoroscopy. Patient was extubated the following day and discharged after 8 days. 3. A 9 year old boy post tetralogy of Fallot repair had severe distal stenosis of the right ventricular to PA conduit.With patient on partial cardiopulmonary bypass, an incision was made on the conduit and a CP 8 Zig 16 stent placed on the stenosis. The child passed on full bypass and the definitive placement of the stent achieved. The child was extubated at the end of the intervention and discharged after 6 days. 4. A newborn presented at 2 days life with complex aortic arch anatomy: left aortic arch and right descending thoracic aorta perfused directly from a right arterial duct and left PA atresia. The arterial duct was stented with a Genesis XD stent dilated at 7mm. Two days later the cardiac surgeon made banded the right PA. The child was extubated after the operation and discharged a week later. Conclusion: Hybrid approach opens new ways of correction or palliation in congenital heart disease with encouraging results and less morbidity.

Fluorine MR Imaging of Inflammation in Atherosclerotic Plaque in Vivo.

PURPOSE: To preliminarily test the hypothesis that fluorine 19 ((19)F) magnetic resonance (MR) imaging enables the noninvasive in vivo identification of plaque inflammation in a mouse model of atherosclerosis, with histologic findings as the reference standard. MATERIALS AND METHODS: The animal studies were approved by the local animal ethics committee. Perfluorocarbon (PFC) emulsions were injected intravenously in a mouse model of atherosclerosis (n = 13), after which (19)F and anatomic MR imaging were performed at the level of the thoracic aorta and its branches at 9.4 T. Four of these animals were imaged repeatedly (at 2-14 days) to determine the optimal detection time. Repeated-measures analysis of variance with a Tukey test was applied to determine if there was a significant change in (19)F signal-to-noise ratio (SNR) of the plaques and liver between the time points. Six animals were injected with a PFC emulsion that also contained a fluorophore. As a control against false-positive results, wild-type mice (n = 3) were injected with a PFC emulsion, and atherosclerotic mice were injected with a saline solution (n = 2). The animals were sacrificed after the last MR imaging examination, after which high-spatial-resolution ex vivo MR imaging and bright-field and immunofluorescent histologic examination were performed. RESULTS: (19)F MR signal was detected in vivo in plaques in the aortic arch and its branches. The SNR was found to significantly increase up to day 6 (P < .001), and the SNR of all mice at this time point was 13.4 ± 3.3. The presence of PFC and plaque in the excised vessels was then confirmed both through ex vivo (19)F MR imaging and histologic examination, while no signal was detected in the control animals. Immunofluorescent histologic findings confirmed the presence of PFC in plaque macrophages. CONCLUSION: (19)F MR imaging allows the noninvasive in vivo detection of inflammation in atherosclerotic plaques in a mouse model of atherosclerosis and opens up new avenues for both the early detection of vulnerable atherosclerosis and the elucidation of inflammation mechanisms in atherosclerosis.

Fatal Cervical Spine Injury From Diving Accident.

Spinal cord injuries result after diving into shallow water, often after incautious jumps head first into water of unknown depth during recreational or sport activities. Mortality is generally due to upper cervical trauma. The authors present a case of a diving-related death in a young woman who underwent medicolegal investigations. The measured water depth at the supposed dive site was 1.40 m. Postmortem radiology and autopsy revealed fractures of the body and the posterior arch of the fifth cervical vertebra, a fracture of the right transverse process of the sixth cervical vertebra and hemorrhages involving the cervical paraspinal muscles. Neuropathology showed a posterior epidural hematoma involving the whole cervical region and a symmetric laceration of the spinal cord located at the fourth and fifth cervical vertebra level, surrounded by multiple petechial hemorrhages. Toxicology revealed the presence of ethanol in both blood and urine samples. The death was attributed to cervical spine fracture (C5-C6), spinal cord contusion, and subsequent drowning. This case highlights the usefulness of postmortem radiology, examination of the deep structures of the neck, toxicology, neuropathology, and a detailed research of signs of drowning to formulate appropriate hypotheses pertaining to the cause and mechanism of death.