Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndromes: Rational for "Double" and "Triple" Rule-Out Concepts

PURPOSE To evaluate the prevalence of acute coronary syndrome (ACS) in patients presenting initially with atypical chest pain and suspected to have pulmonary embolism (PE) or acute aortic syndromes (AAS). To evaluate the overlap between ACS, PE and AAS in routine practice and determine how many patients could have benefit from a single CT protocol to rule out ACS at the same time as PE and AAS. METHOD AND MATERIALS Our electronic hospital database revealed 1122 consecutive patients who underwent a thoracic CT angiography for PE or AAS from 2004 to 2006 (mean age, 63±13 years). Patients without chest pain were excluded from this study. Thus, 447 patients presented with isolated atypical chest were included in the analysis. All patients who underwent a thoracic CT scan previously received standard clinical care and were initially considered as non ACS. The final diagnosis was obtained by the hospital stay report. RESULTS Among the 447 patients with atypical chest pain, 25 (5.5%) were finally found to have ACS: 19 patients (4.2%) were suspected for PE and 6 (1. 3%) were suspected for AAS. There were 90 patients diagnosed to have PE, 89 (98.8%) of them were suspected for PE while only 1 (1%) was suspected for AAS. Eleven patients diagnosed to have AAS, 9 (82%) of them were suspected for AAS while 2 (18%) were suspected for PE. CONCLUSION In clinical practice, the overlap between PE, AAS and ACS is limited which make the triple rule-out studies less recommended to be done at the time being because of the high dose radiation. A double rule-out investigation is suggested to be done for patients being evaluated for atypical chest pain and suspected of having AAS or PE because of a significant overlap between the two entities as well it doesn't implicate any increment in radiation dose. CLINICAL RELEVANCE/APPLICATION With 64-slice CT, coronary circulation and total chest can be evaluated at the same time offering new opportunitie for the evaluation of three major life-threatening conditions :ACS,PE and AAS.

1999-2009 trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland.

BACKGROUND: There are no time trends in prevalence, unawareness, treatment, and control of hypertension in Switzerland. The objective of this study was to analyze these trends and to determine the associated factors. METHODS/FINDINGS: Population-based study conducted in the Canton of Geneva, Switzerland, between 1999 and 2009. Blood pressure was measured thrice using a standard protocol. Hypertension was defined as mean systolic or diastolic blood pressure ≥140/90 mmHg or self-reported hypertension or anti-hypertensive medication. Unawareness, untreated and uncontrolled hypertension was determined by questionnaires/blood pressure measurements. Yearly age-standardized prevalences and adjusted associations for the 1999-2003 and 2004-2009 survey periods were reported. The 10-year survey included 9,215 participants aged 35 to 74 years. Hypertension remained stable (34.4%). Hypertension unawareness decreased from 35.9% to 17.7% (P<0.001). The decrease in hypertension unawareness was not paralleled by a concomitant absolute increase in hypertension treatment, which remained low (38.2%). A larger proportion of all hypertensive participants were aware but not treated in 2004-2009 (43.7%) compared to 1999-2003 (33.1%). Uncontrolled hypertension improved from 62.2% to 40.6% between 1999 and 2009 (P = 0.02). In 1999-2003 period, factors associated with hypertension unawareness were current smoking (OR = 1.27, 95%CI, 1.02-1.59), male gender (OR = 1.56, 1.27-1.92), hypercholesterolemia (OR = 1.31, 1.20-1.44), and older age (OR 65-74yrs vs 35-49yrs  = 1.56, 1.21-2.02). In 1999-2003 and 2004-2009, obesity and diabetes were negatively associated with hypertension unawareness, high education was associated with untreated hypertension (OR = 1.45, 1.12-1.88 and 1.42, 1.02-1.99, respectively), and male gender with uncontrolled hypertension (OR = 1.49, 1.03-2.17 and 1.65, 1.08-2.50, respectively). Sedentarity was associated with higher risk of hypertension and uncontrolled hypertension in 1999-2003. CONCLUSIONS: Hypertension prevalence remained stable since 1999 in the canton of Geneva. Although hypertension unawareness substantially decreased, more than half of hypertensive subjects still remained untreated or uncontrolled in 2004-2009. This study identified determinants that should guide interventions aimed at improving hypertension treatment and control.

Local heating of human skin causes hyperemia without mediation by muscarinic cholinergic receptors or prostanoids.

RESUME Les changements locaux de la température à la surface de la peau humaine ont une influence importante sur sa perfusion. La chaleur augmente localement le flux sanguin cutané, mais les mécanismes et les médiateurs de cette réponse (réponse thermique d'hyperémie) sont incomplètement élucidés. Dans la présente étude, nous avons examiné la relation possible entre la réponse thermique d'hyperémie, les récepteurs cholinergiques muscariniques et la production des prostaglandines vasodilatatrices. Chez 13 sujets de sexe masculin en bonne santé âgés entre 20 et 30 ans, une chambre métallique (contenant de l'eau) dont la température peut être contrôlée, a été placée sur la face palmaire de leur avant-bras et utilisée pour augmenter la température de surface de 34 à 41°C. L'hyperémie cutanée consécutive a été enregistrée par l'intermédiaire d'un scanner laser-Doppler. Dans une expérience, chacun des 8 sujets a reçu un bolus i.v. de glycopyrolate (agent antimuscarinique) (4 µg/kg) lors d'une visite et de NaCl 0,9% lors de l'autre visite. La réponse thermique d'hyperémie a été déterminée dans l'heure suivant les injections. Les glycopyrolate a efficacement empêché la vasodilation des micro-vaisseaux cutanés induite par iontophorèse d'acétylcholine mais n'a pas influencé la réponse thermique d'hyperémie. Dans une deuxième expérience entreprise avec 5 autres sujets 1 g d'aspirine (inhibiteur de la cyclooxygénase) administrée oralement a totalement supprimé la vasodilatation induite dans la peau par le courant anodique, sans modifier la réponse thermique d'hyperémie. La présente étude confirme l'absence de stimulation des récepteurs muscariniques et la production de prostaglandines vaso-dilatatrices dans la vasodilatation induite chez l'homme par réchauffement local de la peau de l'avant-bras. ABSTRACT Local changes in surface temperature have a powerful influence on the perfusion of human skin. Heating increases local skin blood flow (SkBF), but the mechanisms and mediators of this response (thermal hyperemia response) are incompletely elucidated. In the present study, we examined the possible dependence of the thermal hyperemia response on stimulation of muscarinic cholinergic receptors and on production of vasodilator prostanoids. In 13 male healthy subjects aged 20 - 30 years, a temperature- controlled chamber was positioned on the volar face of one forearm and used to raise surface temperature from 34to41°C. The time-course of the resulting thermal hyperemia response was recorded with a laser-Doppler imager. In one experiment, each of 8 subjects received an i.v. bolus of the antimuscarinic agent glycopyrrolate (4µg/kg) on one visit and saline on the other. The thermal hyperemia response was determined within the hour following the injections. Glycopyrrolate effectively inhibited the skin vasodilation induced by iontophoresis of acetylcholine, but did not influence the thermal hyperemia response. In a second experiment conducted in 5 other subjects, 1 gram of the cyclooxygenase inhibitor aspirin administered orally totally abolished the vasodilation induced in the skin by anodal current, but also failed to modify the thermal hyperemia response. The present study excludes the stimulation of muscarinic receptors and the production of vasodilator prostaglandins as essential and nonredundant mechanisms for the vasodilation induced by local heating in human forearm skin.

Pilot study of induction chemotherapy followed by concomitant chemotherapy and IMRT or tomotherapy for nasopharyngeal carcinoma

Objective: Standard treatment of locally advanced (stages III and IV A-B) nasopharyngeal carcinoma (NPC) consists in chemoradiotherapy with 5-y survival rates of around 60%. However, acute toxicity prevents the administration of adequate adjuvant chemotherapy in nearly half of the patients. This situation has led to the hypothesis that induction chemotherapy followed by chemoradiotherapy may be a superior approach. Many ongoing studies are testing the role of induction chemotherapy in this setting. Newer radiotherapy techniques are becoming available (intensity modulated radiotherapy [IMRT] and tomotherapy). They can achieve a higher degree of accuracy in conforming the radiation to the planned target volume while sparing normal tissue resulting in less acute and long-term toxicity. Methods: We report here our local experience of 11 consecutive locally advanced NPC patients treated between June 2004 and October 2007. Median age was 46 years (range, 17-65). All but one were male patients. Initial stage was stage III in 5, and stage IVA-B in 6 patients. Treatment consisted of 3 cycles of induction TCF (Docetaxel 75 mg/m2- Cisplatin 75 mg/m2- 5-fluorouracil 750 mg/m2/d 5 days) chemotherapy followed by concomitant chemoradiotherapy with 3 cycles of cisplatin (100 mg/m2), or carboplatin (AUC 5) in case of renal impairment. Radiotherapy was delivered by either IMRT or tomotherapy. Macroscopic disease (tumor + involved lymph nodes) was treated with 70 Gy, 2 Gy/fraction (IMRT), or 69.6 Gy, 1.12 Gy/fraction (simultaneus integrated boost [SIB] technique). Elective nodal irradiation of 46-54 Gy lymph was performed in all patients, whereas elective irradiation of the entire nasopharynx (60 Gy) half of patients. Results: All but one tumor were EBV positive. Induction chemotherapy was done as planned for 8 patients (73%). Two patients had only 2 cycles, 1 patient had only1 cycle of TCF, and the other without docetaxel. Concomitant chemotherapy was given as planned in 7 patients (64%). Four patients had only 2 cycles. Radiotherapy could be delivered as planned in all patients. Eight weeks post treatment all patients proved to have a CR (CR or uCR). After a median follow-up of 11 months (range, 6-38 months) only one patient has relapsed. Details on acute and 1 year toxicities will be presented. Conclusion: Treatment of locally advancedNPC with induction and concomitant chemotherapy is feasible and well tolerated. The use of IMRT or tomotherapy technique seems to ameliorate the therapeutic index particularly in regard with xerostomia. All our patients presented a complete response. For the assessment of survival and long-term toxicity, a longer follow-up period is needed.

Preliminary Experience in Treatment of Papillary and Macular Retinoblastoma: Evaluation of Local Control and Local Complications After Treatment with Linear Accelerator-Based Stereotactic Radiotherapy with Micromultileaf Collimator as Second-Line or Salvage Treatment after chemotherapy.

PURPOSE: To determine the local control and complication rates for children with papillary and/or macular retinoblastoma progressing after chemotherapy and undergoing stereotactic radiotherapy (SRT) with a micromultileaf collimator. METHODS AND MATERIALS: Between 2004 and 2008, 11 children (15 eyes) with macular and/or papillary retinoblastoma were treated with SRT. The mean age was 19 months (range, 2-111). Of the 15 eyes, 7, 6, and 2 were classified as International Classification of Intraocular Retinoblastoma Group B, C, and E, respectively. The delivered dose of SRT was 50.4 Gy in 28 fractions using a dedicated micromultileaf collimator linear accelerator. RESULTS: The median follow-up was 20 months (range, 13-39). Local control was achieved in 13 eyes (87%). The actuarial 1- and 2-year local control rates were both 82%. SRT was well tolerated. Late adverse events were reported in 4 patients. Of the 4 patients, 2 had developed focal microangiopathy 20 months after SRT; 1 had developed a transient recurrence of retinal detachment; and 1 had developed bilateral cataracts. No optic neuropathy was observed. CONCLUSIONS: Linear accelerator-based SRT for papillary and/or macular retinoblastoma in children resulted in excellent tumor control rates with acceptable toxicity. Additional research regarding SRT and its intrinsic organ-at-risk sparing capability is justified in the framework of prospective trials.

Be fit or be sick: peroxisome proliferator-activated receptors are down the road.

Investigating metabolism by unveiling the functions of the nuclear receptors peroxisome proliferator-activated receptors (PPARs) in the numerous intricate pathways ensuring energy homeostasis and fitness has been extremely rewarding. Major lines of research were initially determined by the first-characterized crucial roles of PPARalpha in fatty oxidation and of PPARgamma in adipocyte differentiation and lipid storage. Today, the molecular bases of the functional links between glucose, lipid, and protein metabolism, under the important but nonexclusive control of PPARalpha and PPARgamma, are starting to be uncovered. In addition, in the last couple of years evidence has been provided for an important role of PPARbeta (delta) in lipid metabolism. Inevitably, such actors of metabolic homeostasis are implicated in the physiopathology of complex metabolic disorders, such as those constituting the metabolic syndrome, resulting in atherosclerosis and cardiovascular diseases. This review presents a summary of the recent findings on their dual involvement in health and disease.

Accès sans prescription aux statines: bénéfique ou délétère. [Over-the-counter statins: benefit or harmful?]

Making statin available over the counter is one of the measures proposed to correct its underuse. Since May 2004, simvastatin 10 mg is sold over the counter in Great Britain. But uncertainties persist concerning the efficacy of statin in primary prevention and at a 10 mg dose. Finally, there is a risk of side effects and drug interactions. Beyond the correction of statin underuse and the hope of coronary heart disease mortality reduction, the British decision highlighted the will to give individuals a sense of responsibility concerning their health and its financial cost. Anyway, the benefit of switching statin from prescription to over the counter should be experimentally evaluated before its introduction.

Anxiety and Psychological Stress Before Prenatal Screening in First-Time Mothers Who Conceived Through IVF/ICSI or Spontaneously.

Mothers' general anxiety, anxiety about the well-being of the child and psychological stress before prenatal testing was studied by comparing women who conceived through in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) with women who conceived naturally. Before the first trimester screening test for Down's syndrome, a group of 51 women who conceived through IVF/ICSI and a group of 54 women who conceived spontaneously completed the State Scale of the State-Trait Anxiety Inventory (S-Anxiety; Spielberger, 1983), the Fear of Bearing a Physically or Mentally Handicapped Child Subscale of the Pregnancy-related Anxiety Questionnaire (PRAQ-R; Huizink et al., 2004), the Psychological Stress Measure (PSM; Lemyre & Tessier, 1988), and the Prenatal Psychosocial Profile (PPP; Curry, Campbell, & Christian, 1994). Women who conceived through IVF/ICSI had more elevated levels of general anxiety and psychological stress than the women who conceived naturally; however, no difference was observed between the two groups for anxiety specifically related to the health of the child. These results underline the need to monitor women's emotional state after conception via IVF/ICSI-when counseling usually ends-and around the time of the first trimester screening. Counseling might thus be extended.

Surgical approach for total hip arthroplasty: direct lateral or posterior?

OBJECTIVE: To determine the risks of prosthesis dislocation, postoperative Trendelenburg gait, and sciatic nerve palsy after a posterior approach compared to a direct lateral approach for adult patients undergoing total hip arthroplasty (THA) for primary osteoarthritis (OA). METHODS: Medline, Embase, CINHAL, and Cochrane databases were searched until August 2003. All published trials comparing posterior and direct lateral surgical approaches to THA in adults with a diagnosis of primary hip osteoarthritis were collected. Retrieved articles were assessed independently for their methodological quality. RESULTS: Four prospective cohort studies involving 241 participants met the inclusion criteria. Regarding dislocation rate, no significant difference between posterior and direct lateral surgical approach was found (relative risk 0.35). The presence of postoperative Trendelenburg gait was not significantly different between surgical approaches. The risk of nerve palsy or injury was significantly higher with the direct lateral approach (relative risk 0.16). However, there were no significant differences when comparing this risk nerve by nerve, in particular for the sciatic nerve. Of the other outcomes considered, only the average range of internal rotation in extension of the hip was significantly higher (weighted mean difference 16 degrees ) in the posterior approach group (mean 35 degrees, SD 13 degrees ) compared to the direct lateral approach (mean 19 degrees, SD 13 degrees ). CONCLUSION: The quality and quantity of information extracted from the trials performed to date are insufficient to make a firm conclusion on the optimum choice of surgical approach for adult patients undergoing primary THA for OA.