Indications à la coronarographie en urgence. Partie II: syndromes coronariens aigus sans élévation du segment ST [Indications for urgent coronary angiography. Part II: Acute coronary syndromes without ST-segment elevation]

The optimal treatment strategy for patients presenting with an acute coronary syndrome without ST elevation is controversial and different therapeutic approaches are recognized. Currently, given the literature available, it is not possible to recommend a universal systematic invasive approach. It is essential to individually risk stratify patients in order to identify those high risk patients that have been shown to benefit from an invasive strategy. Compared to conservative medical treatment, patients at low risk have not been shown to benefit from an invasive strategy. Urgent coronary angiography remains recommended for those patients with persistent or recurrent ischemic symptoms under optimal medical treatment.

Characterization of lower-limbs inter-segment coordination during the take-off extension in ski jumping.

Take-off, the most important phase in ski jumping, has been primarily studied in terms of spatio-temporal parameters; little is known about its motor control aspects. This study aims to assess the inter-segment coordination of the shank-thigh and thigh-sacrum pairs using the continuous relative phase (CRP). In total 87 jumps were recorded from 33 athletes with an inertial sensor-based system. The CRP curves indicated that the thighs lead the shanks during the first part of take-off extension and that the shanks rotated faster at the take-off extension end. The thighs and sacrum first rotated synchronously, with the sacrum then taking lead, with finally the thighs rotating faster. Five characteristic features were extracted from the CRP and their relationship with jump length was tested. Three features of the shank-thigh pair and one of the thigh-sacrum pair reported a significant association with jump length. It was observed that athletes who achieved longer jumps had their thighs leading their shanks during a longer time, with these athletes also having a more symmetric movement between thighs and sacrum. This study shows that inter-segment coordination during the take-off extension is related to performance and further studies are necessary to contrast its importance with other ski jumping aspects.

Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation.

OBJECTIVE: To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment. DESIGN: Prospective before-after evaluation over a 3-month period. SETTING: The emergency ward of a tertiary teaching hospital. PATIENTS: All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods. INTERVENTION: Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team. MAIN OUTCOME MEASURES: Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation. RESULTS: The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment. CONCLUSION: Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.

Measurement of multi-segment foot joint angles during gait using a wearable system.

Usually the measurement of multi-segment foot and ankle complex kinematics is done with stationary motion capture devices which are limited to use in a gait laboratory. This study aimed to propose and validate a wearable system to measure the foot and ankle complex joint angles during gait in daily conditions, and then to investigate its suitability for clinical evaluations. The foot and ankle complex consisted of four segments (shank, hindfoot, forefoot, and toes), with an inertial measurement unit (3D gyroscopes and 3D accelerometers) attached to each segment. The angles between the four segments were calculated in the sagittal, coronal, and transverse planes using a new algorithm combining strap-down integration and detection of low-acceleration instants. To validate the joint angles measured by the wearable system, three subjects walked on a treadmill for five minutes at three different speeds. A camera-based stationary system that used a cluster of markers on each segment was used as a reference. To test the suitability of the system for clinical evaluation, the joint angle ranges were compared between a group of 10 healthy subjects and a group of 12 patients with ankle osteoarthritis, during two 50-m walking trials where the wearable system was attached to each subject. On average, over all joints and walking speeds, the RMS differences and correlation coefficients between the angular curves obtained using the wearable system and the stationary system were 1 deg and 0.93, respectively. Moreover, this system was able to detect significant alteration of foot and ankle function between the group of patients with ankle osteoarthritis and the group of healthy subjects. In conclusion, this wearable system was accurate and suitable for clinical evaluation when used to measure the multi-segment foot and ankle complex kinematics during long-distance walks in daily life conditions.

Whole anterior segment proton beam radiotherapy for diffuse iris melanoma.

AIM: To report the results of whole anterior segment proton beam radiotherapy (PBR) for diffuse iris melanoma. METHODS: Between 2000 and 2011, 12 patients with iris melanoma received PBR to the entire iris and ciliary body. RESULTS: Patients had a mean age of 57 years and a median follow-up of 3.5 years (range 1-11.6 years). Tumour iris involvement was 1-4 h in five patients, 5-8 h in four and 9-12 h in three. Angle involvement was 6-8 h in five patients and 9-12 h in seven. The visual acuity (VA) before treatment was 6/5-6/6 in six patients, 6/8-6/9 in three and 6/18-6/38 in three. No tumour recurrence occurred during the follow-up period. Glaucoma treatment was required in 11 of 12 patients. The visual acuity at the last follow-up was 6/5-6/9 in five patients, 6/18-6/24 in three, 6/60-1/60 in two and no light perception in two. Four patients developed varying non-severe degrees of limbal stem cell deficiency, which was treatable with conservative measures. CONCLUSIONS: Whole anterior segment PBR is a useful alternative to enucleation for diffuse iris melanoma. Most patients will need treatment for glaucoma and some may require treatment for tear-film instability and/or stem cell failure.

Visualization of aqueous shunt position and patency using anterior segment optical coherence tomography.

PURPOSE: To describe the use of anterior segment optical coherence tomography (AS-OCT) to clarify the position and patency of aqueous shunt devices in the anterior chamber of eyes where corneal edema or tube position does not permit a satisfactory view. DESIGN: Noncomparative observational case series. METHODS: Four cases are reported in which aqueous shunt malposition or obstruction was suspected but the shunt could not be seen on clinical examination. The patients underwent AS-OCT to identify the position and patency of the shunt tip. RESULTS: In each case, AS-OCT provided data regarding tube position and/or patency that could not be obtained by slit-lamp examination or by gonioscopy that influenced management. CONCLUSIONS: AS-OCT can be used to visualize anterior chamber tubes in the presence of corneal edema that precludes an adequate view or in cases where the tube is retracted into the cornea. In such cases, AS-OCT is useful in identifying shunt patency and position, which helps guide clinical decision making.

Vectorisation intra-oculaire [Drug delivery to target the posterior segment of the eye].

Retinal diseases are nowadays the most common causes of vision threatening in developed countries. Therapeutic advances in this field are hindered by the difficulty to deliver drugs to the posterior segment of the eye. Due to anatomical barriers, the ocular biodisponibility of systemically administered drugs remains poor, and topical instillation is not adequate to achieve therapeutic concentrations of drugs in the back of the eye. Ocular drug delivery has thus become one of the main challenges of modern ophthalmology. A multidisciplinary research is being conducted worldwide including pharmacology, biomaterials, ophthalmology, pharmaceutics, and biology. New promising fields have been developed such as implantable or injectable slow release intravitreal devices and degradable polymers, dispersed polymeric systems for intraocular drug delivery, and transscleral delivery devices such as iontophoresis, osmotic pumps or intra-scleraly implantable materials. The first clinical applications emerging from this research are now taking place, opening new avenues for the treatment of retinal diseases.

Anterior Segment Angiography in Strabismus Surgery

Background: Anterior ciliary arteries travelling along recti muscles provide anterior segment vascularization, which can be compromised by surgery involving more than 2 muscles.Patients and Methods: We studied retrospectively the files of 10 patients in whom a fluorescein angiography of the iris had been performed as a pre-operative assessment prior to a second or third oculomotor surgery.Results: The median age of the patients was 47.5 years (range 15 to 73 years). Relative iris ischemia was present in 4 patients following multiple surgeries, none of them presenting any general cardiovascular risk. The initial surgical protocol was modified according to angiographic results in these 4 patients.Conclusion: When further surgery has to be performed on previously multi-operated patients, anterior segment angiography can be useful in the planning of surgery in order to minimize the risks of anterior segment ischemia.

Systèmes de délivrance des médicaments pour le segment antérieur: bases fondamentales et applications cliniques [Drug delivery systems to target the anterior segment of the eye: fundamental bases and clinical applications].

The development of new drug delivery systems to target the anterior segment of the eye may offer many advantages: to increase the biodisponibility of the drug, to allow the penetration of drug that cannot be formulated as solutions, to obtain constant and sustained drug release, to achieve higher local concentrations without systemic effects, to target more specifically one tissue or cell type, to reduce the frequency of instillation and therefore increase the observance and comfort of the patient while reducing side effects of frequent instillation. Several approaches are developed, aiming to increase the corneal contact time by modified formulation or reservoir systems, or by increasing the tissue permeability using iontophoresis. To date, no ocular drug delivery system is ideal for all purposes. To maximize treatment efficacy, careful evaluation of the specific pathological condition, the targeted Intraocular tissue and the location of the most severe pathology must be made before selecting the method of delivery most suitable for each individual patient.

Indications à la coronarographie en urgence. Partie I: syndromes coronariens aigus avec élévation du segment ST [Indications for urgent coronary angiography. Part I: ST-segment elevation acute coronary syndromes]

The indications for urgent coronary angiography are stated in the guidelines for treatment of acute coronary syndromes. An invasive approach is considered the treatment of choice for patients presenting with ST elevation myocardial infarction within 12 hours of the beginning of symptoms. In the absence of contraindication, intravenous thrombolysis continues to be a valuable alternative to primary angioplasty within 3 hours of the beginning of clinical symptoms. Urgent coronary angiography continues to be recommended following the failure of thrombolysis, persistent myocardial ischemia after 12 hours of symptoms, recurrent myocardial ischemia following myocardial infarction or in the case of cardiogenic shock.

Événements et déformations tardi-métamorphiques dans le segment Ossola-Ticino (Val Vigezzo-Centovalli, Italie-Suisse)

RESUME: Une zone tectonique large et complexe, connue sous le nom de ligne des Centovalli, traverse le secteur des Alpes Centrales compris entre Domodossola et Locarno. Cette région, formée par le Val Vigezzo et la vallée des Centovalli, constitue la terminaison méridionale du dôme Lepontin et représente une portion de la zone des racines des nappes alpines. Elle fait partie d’une grande et complexe zone de cisaillement, en partie associée à des phénomènes hydrothermaux d’âge alpin (<20 Ma), qui comprend le système tectonique Insubrien et celui du Simplon. Le Val Vigezzo et les Centovalli constituent un vrai carrefour entre les principaux accidents tectoniques des Alpes ainsi qu'une zone de juxtaposition du socle Sudalpin avec la zone des racines de l’Austroalpin et du Pennique. Les phases de déformation et les structures géologiques qui peuvent être étudiées s'étalent sur une période comprise entre environ 35 Ma et l'actuel. L’étude détaillée de terrain a mis en évidence la présence de nombreuses roches et structures de déformation de type ductile et cassant tels que des mylonites, des cataclasites, des pseudotachylites, des kakirites, des failles minéralisées, des gouges de faille et des plis. Sur le terrain on a pu distinguer au moins quatre générations de plis liés aux différentes phases de déformation. Le nombre et la complexité de ces structures indiquent une histoire très compliquée, selon plusieurs étapes distinctes, parfois liées, voire même superposées. Une partie de ces structures de déformation affectent aussi les dépôts sédimentaires d’âge quaternaire, notamment des limons et des sables lacustres. Ces sédiments constituent les restes d'un bassin lacustre attribué à l'époque interglaciaire Riss/Würm (éemien, 67.000-120.000 ans) et ils affleurent dans la partie centrale de la zone étudiée, à l'Est de la plaine de Santa Maria Maggiore. Ces sédiments montrent en leur sein toute une série de structures de déformation tels que des plans de faille inverses, des structures conjuguées de raccourcissement et des véritables plis. Ces failles et ces plis représenteraient les évidences de surface d’une déformation probablement active en époque quaternaire. Une autre formation rocheuse a retenu tout notre attention; il s'agit d'un corps de brèches péridotitiques monogéniques qui affleure en discontinuité le long du versant méridional et le long du fond de la vallée Vigezzo sur environ 20 km. Ces brèches se posent indifféremment sur le socle (unités Finero, Orselina) ou sur les sédiments lacustres. Elles sont traversées par des plans de failles qui développent des véritables stries de faille et des gouges de faille; l’orientation de ces plans est la même que celle affectant les failles à gouges du socle. La genèse de cette brèche est liée à l'altération et au modelage glacier (rock-glaciers) d'une brèche tectonique originelle qui borde la partie externe du Corps de Finero. Les structures de déformation de cette brèche, pareillement à celles des sédiments lacustres, ont été considérées comme les évidences de surface d'une tectonique quaternaire active dans la région. La dernière phase de déformation cassante qui affecte cette région peut donc être considérée comme active en époque quaternaire. Une vue d’ensemble de la région étudiée nous permet de reconnaître à l’échelle régionale une zone de cisaillement complexe orientée E-W, parallèlement à l’axe de la vallée Centovalli-Val Vigezzo. Les données de terrain, indiquent que cette zone de cisaillement débute sous conditions ductiles et évolue en plusieurs étapes jusqu’à des conditions de failles cassantes de surface. La reconstruction de l'évolution géodynamique de la région a permis de définir trois étapes distinctes qui marquent le passage, de ce secteur de socle cristallin, de conditions P-T profondes à des conditions de surface. Dans ce contexte, on a reconnu trois phases principales de déformation à l’échelle régionale qui caractérisent ces trois étapes. La phase la plus ancienne est constituée par des mylonites en faciès amphibolite, associées à des mouvements de cisaillement dextre, qui sont ensuite remplacés par des mylonites en faciès schistes verts et des plis rétrovergentes liés au rétrocharriage des nappes alpines. Une deuxième étape est identifiée par le développement d’une phase hydrothermale liée à un système de failles extensives et décrochantes dextres à direction principale E-W, NE-SW et NW-SE. Leur caractérisation minéralogique a permis la mise en évidence des phases cristallines de néoformation liées à cet événement constituées par : K-feldspath (microcline), chlorites (Fe+Mg), épidotes, prehnite, zéolites (laumontite), sphène, calcite. Dans ce contexte, pour obtenir une meilleure caractérisation de cet événement hydrothermal on a utilisé des géothermomètres sur chlorites, sensible aussi à la pression et a la a(H2O), qui ont donné des valeurs descendantes comprises entre 450-200°C. Les derniers mouvements sont mis en évidence par le développement d’une série de plans majeurs de failles à gouge, qui forment une structure en sigmoïdes d’épaisseur kilométrique reconnaissable à l’échelle de la vallée et caractérisée par des mouvements transpressifs avec une composante décrochante dextre toujours importante. Cette phase de déformation forme un système conjugué de failles avec direction moyenne E-W qui coupent la zone des racines des nappes alpines, la zone du Canavese et le corps ultramafique de Finero. Ce système se déroule de manière subparallèle à l'axe de la vallée le long de plusieurs dizaines de kilomètres. Une analyse complète et détaillée des gouges de faille par XRD a montré que la fraction argileuse (<2 µm) de ces gouges contient une partie de néoformation très importante constituée par, des illites, des chlorites et des interstratifiés de type illite/smectite ou chlorite/smectite. Des datations avec méthode K-Ar sur ces illites ont donné des valeurs comprises entre 12 et 4 Ma qui représentent l'âge de cette dernière déformation cassante. L'application de la méthode de la cristallinité de l'illite (C.I.) a permis d'évaluer les conditions thermiques qui caractérisent le déroulement de cette dernière phase tectonique qui se produit sous conditions de température caractéristiques de l'anchizone et de la diagenèse. L'ensemble des structures de déformation qu'on vient de décrire s'insère parfaitement dans le contexte de convergence oblique entre la plaque adriatique et celle européenne qui à produit l'orogène alpin. On peut considérer les structures tectoniques du Val Vigezzo-Centovalli comme l'expression d'une zone majeure de cisaillement "Simplo-Insubrienne". L'empilement structural et les structures tectoniques affleurantes dans la région sont le résultat de l'interaction entre un régime tectonique transpressif et un régime transtensif. Ces deux champs de tension sont antagonistes entre eux mais sont reliés, de toute façon, à une seule phase décrochante dextre principale, due à une convergence oblique entre deux plaques. À l'échelle de l'évolution géodynamique on peut distinguer différentes étapes au cours desquelles les structures de ces deux régimes tectoniques interagissent en manière différente. En accord avec les données géophysiques et les reconstructions paléodynamiques prises dans la littérature on considère que la ligne Rhône-Simplon-Centovalli représente l'évidence de surface de la suture majeure profonde entre la plaque Adriatique et celle Européenne. Les vitesses de soulèvement qui ont été calculées dans cette étude pour cette région des Alpes donnent une valeur moyenne de 0.8 mm/a qui est tout à fait comparable avec les données proposées par la littérature sur cette zone. La zone Val Vigezzo-Centovalli peut être donc considérée comme un carrefour géologique où se croisent différentes phases tectoniques qui représentent les évidences de surface d'une suture profonde majeure entre deux plaques dans un contexte de collision continentale. ABSTRACT: A wide and complex tectonic zone known as Centovalli line, crosses the Central Alps sector between Domodossola and Locarno. This area, formed by the Vigezzo Valley and Centovalli valley, constitutes the southernmost termination of the Lepontin dome and represents a portion of the alpine nappes root zone. It belongs to a large and complex shear-zone, partly associated with hydrothermal phenomena of alpine age (<20 My), which includes the Insubric Line and the Simplon fault zone. Vigezzo Valley and Centovalli constitute a real crossroads between the mains alpines tectonics lines as well as a zone of juxtaposition of the Southalpine basement with the Austroalpin and Pennique root zone. The deformation phases and the geological structures that can be studied between approximately 35 My and the present. The detailed field study showed the presence of many brittle and ductile deformation structures and fault rocks such as mylonites, cataclasites, pseudotachylites, kakirites, mineralized faults, fault gouges and folds. In the field we could distinguish at least four folds generations related to the various deformation phases. The number and the complexity of these structures indicate a very complicated history, comprising several different stages, that sometimes are related and even superimposed. Part of these deformation structures affect also the sedimentary deposits of quaternary age, in particular the silts and sands lake deposit. These sediments constitute the remainders of a lake basin ascribed to the interglacial Riss/Würm (Eemien, 67.000-120.000 years) and outcroping in the central part of the studied area, in the Eastern part of Santa Maria Maggiore plain. These sediments show a whole series of deformation structures such as inverse fault planes, combined shortening structures and true folds. These faults and folds would represent the surface evidence of a probably active tectonic deformation in quaternary time. Another rock formation attracted all our attention. It is a body of monogenic peridotite breccia which outcrops in discontinuity along the southernmost slope and the bottom of the Vigezzo valley on approximately 20 km. This breccia lies indifferently on the basement (Finero and Orselina units) or on the lake sediments. They are crossed by fault planes which developed slikenside and fault gouges whose orientation is the same of the faults gouges in the alpine basement. This breccia results from the weathering and the surface modelling of an original tectonic breccia which borders the external part of Finero peridotite body. This breccia deformation structures, like those of the lake sediments, were regarded as the surface interaction of active quaternary tectonics in the area. So the last brittle deformation phases which affects this area seems to be actives in quaternary time. Theoverall picture of the studied area on a regional scale enables us to point out a complex shear-zone directed E-W, parallel to the axis of the Centovalli and Vigezzo Valley. The field analysis indicates that this shear-zone began under ductile conditions and evolved in several stages to brittle faulting under surface conditions. The analysis of the geodynamic evolution of the area allows to define three different stages which mark the transition of this alpine basement root zone, from deep P-T conditions to P-T surface conditions. In this context on regional scale three principal deformation phases, which characterize these three stages can be distinguished. The oldest phase consisted of the amphibolitie facies mylonites, associated to dextral strikeslip movements. They are then replaced by green-schists facies mylonites and backfolds related to the backthrusting of the alpines nappes. A second episode is caracterized by the development of an hydrothermal phase bound to an extensive fault and dextral strike-slip fault system, with E-W, NW-SE and SE-NW principal directionsThe principal neoformed mineral phases related to this event are: K-feldspar (microcline), chlorites (Fe+Mg), epidotes prehnite, zéolites (laumontite), sphene and calcite. In this context, to obtain a better characterization of this hydrothermal event, we have used an chlorite geothermometer, sensitive also to the pressure and has the a(H2O), which gave downward values ranging between 450-200°C. The last movements are caracterized by the development of important gouge fault plans, which form a sigmoid structure of kilometric thickness which is recognizable at the valley scale, and is characterized by transpressive movements always with a significant dextral strike-slip component. This deformation phase forms a combined faults system with an average E-W direction, which cuts trough the alpine root zone, the Canavese zone and the Finero ultramafic body. This fault system takes place subparallel to the axis of the valley over several tens of kilometers. A complete and detailed XRD analysis of the gouges fault showed that the clay fraction (<2µm) contains a very significant neo-formation of illite, chlorites and mixed layered clays such as illite/smectite or chlorite/smectite. The K-Ar datings of the illite fraction <2µm gave values ranging between 12 and 4 My and the illite fraction <0.2µm gave more recents values until to 2,4-0 My.This values represent the age of this last brittle deformation. The application of the illite crystallinity method (C.I.) allowed evaluating the thermal conditions which characterize this tectonic phase that occured under temperature conditions of the anchizone and diagenesis. The whole set of deformation structures which we just described, perfectly fit the context of oblique convergence between the Adriatic and the European plate that produced the alpine orogen. We can regard the Vigezzo valley and Centovalli tectonic structures as the expression of a major "Simplo-Insubric" shear-zone. Structural stacking and tectonic structures that outcrop in the studied area, are the result of the interaction between a transpressive and a transtensve tectonic phases. These two tension fields are antagonistic but they are also connected, in any event, with only one principal dextral strike-slip movement, caused by an oblique convergence between two plates. On the geodynamic evolution scale we can distinguish various stages during which these two tectonic structures fields interact in various ways. In agreement with the geophysical data and the paleodynamic recostructions taken in the literature we considers that the Rhone-Simplon-Centovalli line are the surface feature of the major collision between the Adriatique and the European plate at depth. The uplift speeds we calculated in this study for this Alpine area give an average value of 0.8 mm/a, which is in good agreement with the data suggested by the literature on this zone. TheVigezzo Valley and Centovalli zone can therefore be regarded as a geological crossroad where various tectonic phases are superimposed. They represent the evidences of a major and deeper suture between two plates in a continental collision context.