Acute coronary syndromes in young patients: presentation, treatment and outcome.

BACKGROUND: Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. METHODS: In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). RESULTS: 195 patients (0.7%) were 35 years old or younger. Compared to patients>35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; P<0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; P<0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. CONCLUSIONS: Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Minorités linguistiques, où êtes-vous ? : pistes et mesures pour une meilleure représentation des minorités linguistiques au sein des organisations (para-)étatiques

L'objectif de la présente étude est d'identifier et d'analyser un certain nombre de mesures et de bouquets de mesures afin de cerner quelques pistes propres à améliorer la représentation des ressortissants des minorités linguistiques francophone ou germanophone au sein d'organisations étatiques ou paraétatiques suisses actives en contexte bilingue allemand-français. Pour ce faire, nous nous sommes appuyé sur la théorie de la bureaucratie représentative et ses promesses et avons recouru à une approche d'acteurs à deux niveaux, comprenant l'envoi d'un questionnaire et l'organisation d'entretiens d'approfondissement. Dix organisations ont ainsi été approchées : Confédération, cantons, communes, anciennes régies fédérales. Il a été possible d'identifier certains enjeux et de cerner un certain nombre de mesures performantes, souvent peu onéreuses en termes de finances et d'organisation ou relevant du bon sens, intervenant à différents moments du cycle de vie d'un emploi et susceptibles d'attirer ou de fidéliser des représentants de la minorité linguistique locale au sein d'une organisation. Il a également été possible de savoir pour quelles raisons certaines mesures sont régulièrement délaissées par les organisations approchées. D'autres ont pu être identifiées au fil d'entretiens, dont certaines sont en projet mais sont susceptibles de se heurter à des obstacles d'ordres divers. D'autres, enfin, sont appelées à se développer. Elles ne sauraient toutefois se passer de soutien politique et juridique, ni d'une certaine créativité, ni d'efforts constants. Ceux-ci déboucheront toutefois sur une organisation plus riche culturellement, s'avérant par ailleurs plus démocratique du fait qu'elle reflétera mieux les citoyens qu'elle administre. Cela, sans oublier une certaine philosophie de souplesse et de tolérance réciproque entre représentants de la minorité et de la majorité linguistique.

The value of serum procalcitonin level for differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

BACKGROUND: Early diagnosis of postoperative orthopaedic infections is important in order to rapidly initiate adequate antimicrobial therapy. There are currently no reliable diagnostic markers to differentiate infectious from noninfectious causes of postoperative fever. We investigated the value of the serum procalcitonin level in febrile patients after orthopaedic surgery. METHODS: We prospectively evaluated 103 consecutive patients with new onset of fever within ten days after orthopaedic surgery. Fever episodes were classified by two independent investigators who were blinded to procalcitonin results as infectious or noninfectious origin. White blood-cell count, C-reactive protein level, and procalcitonin level were assessed on days 0, 1, and 3 of the postoperative fever. RESULTS: Infection was diagnosed in forty-five (44%) of 103 patients and involved the respiratory tract (eighteen patients), urinary tract (eighteen), joints (four), surgical site (two), bloodstream (two), and soft tissues (one). Unlike C-reactive protein levels and white blood-cell counts, procalcitonin values were significantly higher in patients with infection compared with patients without infection on the day of fever onset (p = 0.04), day 1 (p = 0.07), and day 3 (p = 0.003). Receiver-operating characteristics demonstrated that procalcitonin had the highest diagnostic accuracy, with a value of 0.62, 0.62, and 0.71 on days 0, 1, and 3, respectively. In a multivariate logistic regression analysis, procalcitonin was a significant predictor for postoperative infection on days 0, 1, and 3 of fever with an odds ratio of 2.3 (95% confidence interval, 1.1 to 4.4), 2.3 (95% confidence interval, 1.1 to 5.2), and 3.3 (95% confidence interval, 1.2 to 9.0), respectively. CONCLUSIONS: Serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

Assessment of volumetric bone mineral density of the femoral neck in postmenopausal women with and without vertebral fractures using quantitative multi-slice CT.

OBJECTIVE: To demonstrate the validity and reliability of volumetric quantitative computed tomography (vQCT) with multi-slice computed tomography (MSCT) and dual energy X-ray absorptiometry (DXA) for hip bone mineral density (BMD) measurements, and to compare the differences between the two techniques in discriminating postmenopausal women with osteoporosis-related vertebral fractures from those without. METHODS: Ninety subjects were enrolled and divided into three groups based on the BMD values of the lumbar spine and/or the femoral neck by DXA. Groups 1 and 2 consisted of postmenopausal women with BMD changes <-2SD, with and without radiographically confirmed vertebral fracture (n=11 and 33, respectively). Group 3 comprised normal controls with BMD changes > or =-1SD (n=46). Post-MSCT (GE, LightSpeed16) scan reconstructed images of the abdominal-pelvic region, 1.25 mm thick per slice, were processed by OsteoCAD software to calculate the following parameters: volumetric BMD values of trabecular bone (TRAB), cortical bone (CORT), and integral bone (INTGL) of the left femoral neck, femoral neck axis length (NAL), and minimum cross-section area (mCSA). DXA BMD measurements of the lumbar spine (AP-SPINE) and the left femoral neck (NECK) also were performed for each subject. RESULTS: The values of all seven parameters were significantly lower in subjects of Groups 1 and 2 than in normal postmenopausal women (P<0.05, respectively). Comparing Groups 1 and 2, 3D-TRAB and 3D-INTGL were significantly lower in postmenopausal women with vertebral fracture(s) [(109.8+/-9.61) and (243.3+/-33.0) mg/cm3, respectively] than in those without [(148.9+/-7.47) and (285.4+/-17.8) mg/cm(3), respectively] (P<0.05, respectively), but no significant differences were evident in AP-SPINE or NECK BMD. CONCLUSION: the femoral neck-derived volumetric BMD parameters using vQCT appeared better than the DXA-derived ones in discriminating osteoporotic postmenopausal women with vertebral fractures from those without. vQCT might be useful to evaluate the effect of osteoporotic vertebral fracture status on changes in bone mass in the femoral neck.

La dénervation rénale unilatérale et le système kallikréine-bradykinine rénal chez le rat [Unilateral renal denervation and the renal kallikrein-bradykinin system in the rat].

AIM: The antihypertensive effect of renal denervation in hypertensive patients is partially explained by increased tubular natriuresis. To study the possible contribution of the kallikrein-kinin system (KKS) to this natriuretic effect in rats, we measured kallikrein activity (KA) and bradykinin concentrations (BK) in plasma and tissues. METHODS: To measure KA, we adapted and validated an enzymatic assay that cleaves para-nitroaniline (pNA) from the tripeptide H-D-Pro-Phe-Arg-pNA. The coefficients of variation (CV) within- and between-assays were less than 8% for plasma and tissue KA (plasma n=6 and 13; tissue n=4). Linear results for serially diluted samples confirmed the assay specificity. Tissue BK determinations were based on an established assay for plasma BK: tissue was homogenized and kinins extracted in ethanol, and BK was isolated by high-performance (HPLC) liquid chromatography and quantitated by radioimmunassay. Within- and between-assay CV for plasma BK were 18% (n=8 and n=35, respectively) and for BK in various tissues less than 16% (n=5-8). RESULTS: In male Wistar rats (n=3), plasma BK was 8.2±6.6 fmol/mL (mean±SD), and tissue BK (fmol/g) in 14 tested organs varied between brain (14±3) and submaxillary gland (521±315). Six days after left-sided unilateral renal denervation, left renal tissue BK (89±9) was not different from right renal BK (75±23). Similarly, KA was comparable in the two kidneys (left 18.0±1.5, right 15.8±1.4μkat/g). CONCLUSION: Any possible effect of unilateral renal denervation on the kidney's KKS would have to be bilateral.

Not accepted by the family: "Being difficult" or "being different"?

Using data from the Netherlands Kinship Panel Study (NKPS) and combining a quantitative approach and a qualitative approach (N = 8,148 and n = 43, respectively), this study investigates the mechanisms associated with a lack of acceptance by one's family. From the total NKPS sample, 12.1% did not feel (entirely) accepted by their family. The authors hypothesized that people may not feel accepted by their family when they are "difficult," for example, by exhibiting personal problems; another reason might be that they are "different," for instance, because they have made nontraditional life course transitions or differ from their parents in educational level or religious preference. Both quantitative and qualitative results confirm the first hypothesis rather than the second. Qualitative results revealed a gender difference in the mechanisms associated with a lack of acceptance by one's family as well as differences in the resilience of those who had had a difficult family background.

Chicken BAFF--a highly conserved cytokine that mediates B cell survival.

Members of the tumor necrosis factor (TNF) family play key roles in the regulation of inflammation, immune responses and tissue homeostasis. Here we describe the identification of the chicken homologue of mammalian B cell activating factor of the TNF family (BAFF/BLyS). By searching a chicken EST database we identified two overlapping cDNA clones that code for the entire open reading frame of chicken BAFF (chBAFF), which contains a predicted transmembrane domain and a putative furin protease cleavage site like its mammalian counterparts. The amino acid identity between soluble chicken and human BAFF is 76%, considerably higher than for most other known cytokines. The chBAFF gene is most strongly expressed in the bursa of Fabricius. Soluble recombinant chBAFF produced by human 293T cells interacted with the mammalian cell-surface receptors TACI, BCMA and BAFF-R. It bound to chicken B cells, but not to other lymphocytes, and it promoted the survival of splenic chicken B cells in culture. Furthermore, bacterially expressed chBAFF induced the selective expansion of B cells in the spleen and cecal tonsils when administered to young chicks. Our results suggest that like its mammalian counterpart, chBAFF plays an important role in survival and/or proliferation of chicken B cells.

Residual antimalarials in malaria patients from Tanzania--implications on drug efficacy assessment and spread of parasite resistance.

Repeated antimalarial treatment for febrile episodes and self-treatment are common in malaria-endemic areas. The intake of antimalarials prior to participating in an in vivo study may alter treatment outcome and affect the interpretation of both efficacy and safety outcomes. We report the findings from baseline plasma sampling of malaria patients prior to inclusion into an in vivo study in Tanzania and discuss the implications of residual concentrations of antimalarials in this setting. In an in vivo study conducted in a rural area of Tanzania in 2008, baseline plasma samples from patients reporting no antimalarial intake within the last 28 days were screened for the presence of 14 antimalarials (parent drugs or metabolites) using liquid chromatography-tandem mass spectrometry. Among the 148 patients enrolled, 110 (74.3%) had at least one antimalarial in their plasma: 80 (54.1%) had lumefantrine above the lower limit of calibration (LLC = 4 ng/mL), 7 (4.7%) desbutyl-lumefantrine (4 ng/mL), 77 (52.0%) sulfadoxine (0.5 ng/mL), 15 (10.1%) pyrimethamine (0.5 ng/mL), 16 (10.8%) quinine (2.5 ng/mL) and none chloroquine (2.5 ng/mL). The proportion of patients with detectable antimalarial drug levels prior to enrollment into the study is worrying. Indeed artemether-lumefantrine was supposed to be available only at government health facilities. Although sulfadoxine-pyrimethamine is only recommended for intermittent preventive treatment in pregnancy (IPTp), it was still widely used in public and private health facilities and sold in drug shops. Self-reporting of previous drug intake is unreliable and thus screening for the presence of antimalarial drug levels should be considered in future in vivo studies to allow for accurate assessment of treatment outcome. Furthermore, persisting sub-therapeutic drug levels of antimalarials in a population could promote the spread of drug resistance. The knowledge on drug pressure in a given population is important to monitor standard treatment policy implementation.

Oxidative-nitrosative stress and systemic vascular function in highlanders with and without exaggerated hypoxemia.

BACKGROUND: Acute exposure to high altitude stimulates free radical formation in lowlanders, yet whether this persists during chronic exposure in healthy, well-adapted and maladapted highlanders suffering from chronic mountain sickness (CMS) remains to be established. METHODS: Oxidative-nitrosative stress (as determined by the presence of the biomarkers ascorbate radical [A •- ], via electron paramagnetic resonance spectroscopy, and nitrite [NO 2 2 ], via ozone-based chemiluminescence) was assessed in venous blood of 25 male highlanders in Bolivia living at 3,600 m with CMS (n 5 13, CMS 1 ) and without CMS (n 5 12, CMS 2 ). Twelve age- and activity-matched, healthy, male lowlanders were examined at sea level and during acute hypoxia. We also measured fl ow-mediated dilatation (FMD), arterial stiffness defined by augmentation index normalized for a heart rate of 75 beats/min (AIx-75), and carotid intima-media thickness (IMT). RESULTS: Compared with normoxic lowlanders, oxidative-nitrosative stress was moderately increased in the CMS 2 group ( P , .05), as indicated by elevated A •- (3,191 457 arbitrary units [AU] vs 2,640 445 AU) and lower NO 2 2 (206 55 nM vs 420 128 nM), whereas vascular function remained preserved. This was comparable to that observed during acute hypoxia in lowlanders in whom vascular dysfunction is typically observed. In contrast, this response was markedly exaggerated in CMS 1 group (A •- , 3,765 429 AU; NO 2 2 , 148 50 nM) compared with both the CMS 2 group and lowlanders ( P , .05). This was associated with systemic vascular dysfunction as indicated by lower ( P , .05 vs CMS 2 ) FMD (4.2% 0.7% vs 7.6% 1.7%) and increased AIx-75 (23% 8% vs 12% 7%) and carotid IMT (714 127 m M vs 588 94 m M). CONCLUSIONS: Healthy highlanders display a moderate, sustained elevation in oxidative-nitrosative stress that, unlike the equivalent increase evoked by acute hypoxia in healthy lowlanders, failed to affect vascular function. Its more marked elevation in patients with CMS may contribute to systemic vascular dysfunction.

Modelling the effect of minor orthopaedic day surgery on patient mood at the early post-operative period: a prospective population-based cohort study.

OBJECTIVE: The effect of minor orthopaedic day surgery (MiODS) on patient's mood. METHODS: A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of general anaesthesia (GA) were included. The Medical Outcomes Study - Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and post-operatively. RESULTS: The mean physical component score of SF-36 before surgery was 45.3 (SD=+/-10.1) and 8 weeks following surgery was 44.9 (SD=+/-11.04) [n=148, p=0.51, 95% CI=(-1.03 to 1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov=69.44) corresponded to a correlation coefficient, r=0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well with chi(2) (df=1)=0.86 for which p=0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected. CONCLUSIONS: MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.

Heidelberg Retina Tomograph in Glaucoma Case-finding

Purpose: To compare the disease classification using optic nerve head imaging against clinical examination combined with perimetry in the case-finding environment.Methods: During a glaucoma screening event at the University Hospital in Lausanne 148 attendees opted to undergo an extended screening exam consisting of perimetry with Octopus (Haag-Streit, Koeniz, Switzerland), tonometry, gonioscopy, slit-lamp optic nerve head examination and Heidelberg Retinal Tomorgraph (HRT, Heidelberg engineering). Classification criteria of an abnormal clinical exam consisted of a cup to disc ratio > 0.6, other disc abnormality (e.g. notching), closed angles, Van Herrick < ¼ and intraocular pressure >21mmHg. In perimetry a square root loss variance (sLV) >3.0 dB was considered abnormal. Those cases with both an abnormal clinical exam and abnormal perimetric results were considered to be glaucoma suspects. An abnormal HRT exam was a global Moorfields Regression Analysis (MRA) result of "outside normal limits". The results from the worse eye for each instrument are reported.Results: The mean age of the patients was 59.9 years (SD ±14.8years). 46 subjects failed the clinical exam. 55 subjects had sLV>3.0dB. 86 subjects failed one or more of the testing components, 21 subjects failed both the clinical exam and perimetry. Two cases of advanced glaucoma were diagnosed on the day of the event. 20 subjects were referred due to other ocular pathology (10 cataract; 2 AMD; 8 other). 16 subjects were outside normal limits with the HRT, of which 11 failed the clinical exam, 9 failed the perimetric exam and 7 failed all three. HRT had a sensitivity of 33% CI [15%,57%] with a specificity of 93% CI [87%,97%].Conclusions: HRT shows good specificity, however the low sensitivity makes it of limited use in the proposed case finding scenario.

Substances psychoactives au volant: quelle conduite ? [Psychoactive substances and driving: which approach?]

Les problèmes médicaux concernant la conduite automobile deviennent de plus en plus compliqués et de plus en plus fréquents. Dans la plupart des cantons suisses, chaque médecin peut potentiellement être interpellé en tant que médecin-conseil d'un de ses patients. Le présent article s'intéresse particulièrement aux problèmes de toxicodépendance dans le cadre du contexte législatif actuel et de la complexité croissante des soins. Medical problems involving driving aptitude are more and more common nowadays. Each doctor in Switzerland could be asked to give a certificate of driving aptitude for one of his/her patient. This paper relates to the problem of substance abusers in the current legal context and the growing complexity of care.

Lymphoproliferative disorders associated with hypereosinophilia.

Hypereosinophilia, defined as peripheral blood eosinophil counts >1,500/μL, may complicate the course of various lymphoproliferative disorders. Among these, Hodgkin lymphoma (HL) and certain peripheral T-cell lymphomas (PTCLs) derived from CD4 cells, including Sezary syndrome (SS), adult T-cell leukemia/lymphoma (ATLL), and angioimmunoblastic T-cell lymphoma (AITL), are most commonly associated with increased reactive eosinophilopoiesis. Rarely, marked hypereosinophilia (HE) may occur in the setting of acute B-cell lymphoblastic leukemia, with a substantial impact on disease course. The mechanisms leading to blood and tissue eosinophilia in the setting of lymphoproliferative disorders, as well as the clinical complications and prognostic implications of hypereosinophilia, are discussed in this review.

Quelle attitude face à une masse médiastinale antérieure chez l'adulte [Management of anterior mediastinal masses in adults].

The discovery of an anterior mediastinal mass requires careful management with specific consideration of the pathology. More than 50% of all mediastinal masses seen in adults are in the anterior mediastinum. The most frequent diagnoses are thymoma, lymphoma, teratoma and benign thyroid tumours. 60% of cases are malignant. Often the clinical and radiological findings do not allow a definitive diagnosis and a histological diagnosis is often required to select the optimal treatment modality. The choice of biopsy technique depends on the localization of the lesion, clinical factors, and the availability of special techniques and equipment. Biopsy may be obtained by trans-thoracic puncture under computed tomography or ultrasound guidance, or by a surgical approach (mediastinotomy or thoracoscopy).