Anàlisi de l’adherència a les guies de pràctica clínica i de la qualitat dels documents assistencials a la Síndrome Coronària Aguda Sense Elevació del Segment ST a l’Hospital de Sant Pau.

El nivell d’acompliment de les recomanacions de les GPC de la ESC (European Society of Cardiology) per la SCASEST a l’Hospital de Sant Pau als mesos d’octubre a desembre del 2010 és subòptim, similar al d’altres centres americans i europeus, i roman invariable respecte les dades de 2006-2007. El servei de Cardiologia destaca en les recomanacions d’hàbits i control de factors de risc cardiovascular. Existeixen diferències poc rellevants entre els serveis de Cardiologia i Medicina Interna en les recomanacions farmacològiques. No s’ha objectivat una relació significativa entre la qualitat de la informació dels documents assistencials i l’adherència a les GPC.

Prospective evaluation of risk of vertebral fractures using quantitative ultrasound measurements and bone mineral density in a population-based sample of postmenopausal women: results of the Basel Osteoporosis Study.

OBJECTIVE: Prospective studies have shown that quantitative ultrasound (QUS) techniques predict the risk of fracture of the proximal femur with similar standardised risk ratios to dual-energy x-ray absorptiometry (DXA). Few studies have investigated these devices for the prediction of vertebral fractures. The Basel Osteoporosis Study (BOS) is a population-based prospective study to assess the performance of QUS devices and DXA in predicting incident vertebral fractures. METHODS: 432 women aged 60-80 years were followed-up for 3 years. Incident vertebral fractures were assessed radiologically. Bone measurements using DXA (spine and hip) and QUS measurements (calcaneus and proximal phalanges) were performed. Measurements were assessed for their value in predicting incident vertebral fractures using logistic regression. RESULTS: QUS measurements at the calcaneus and DXA measurements discriminated between women with and without incident vertebral fracture, (20% height reduction). The relative risks (RRs) for vertebral fracture, adjusted for age, were 2.3 for the Stiffness Index (SI) and 2.8 for the Quantitative Ultrasound Index (QUI) at the calcaneus and 2.0 for bone mineral density at the lumbar spine. The predictive value (AUC (95% CI)) of QUS measurements at the calcaneus remained highly significant (0.70 for SI, 0.72 for the QUI, and 0.67 for DXA at the lumbar spine) even after adjustment for other confounding variables. CONCLUSIONS: QUS of the calcaneus and bone mineral density measurements were shown to be significant predictors of incident vertebral fracture. The RRs for QUS measurements at the calcaneus are of similar magnitude as for DXA measurements.

Chest pain and ST-segment elevation in a patient with Duchenne muscular dystrophy, what really happened?

Introduction: Myocardial infarction is rare in children, if it occurs, findings are almost similar to adults. In Ouchenne muscular dystrophy (OMO), ST segment displacement associated with typical chest pain can occur. We report the case of a young boy with OMO presenting symptoms suggestive of myocardial ischemia. Case report: 7 year old boy, diagnosed with OMO, eoming to the emergency department with complaints of acute chest pain, dyspnoea and anxiety the night before. Clinical examination was not remarkable, with exception of findings of the OMO. ECG showed important ST-segment elevation in right precordial leads. Major increase in troponin 1 42.33 mcg/(normal, <0.04 mcg/I) was found. Echocardiography revealed slight yskinesia of postero-septal wall without decrease in ventricular function. As acute pain had happened more han 12 hours before referral and as the child was asymptomatic, he received anti-platelets therapy. The serum level of troponin 1 declined and the ECG normalised in a few days. Cardiac catheterization did not show any coronary anomaly or eardiac dysfunction. Cardiac biopsy revealed myocardial cell damaged compatible with OMO cardiomyopathy. Tc99m myocardial single-photon emission computed tomography (SPECT) did not show any radionuclide uptake defect. Conclusions: ln this particular context of children with OMO, the classical signs of myocardial ischemia could be misleading, standard investigation failed to demonstrate the cause of chest pain and inerease of troponin l, there was also no evidence of myocarditis. Role of late enhancement (LE) signal in eontrast-enhanced MRI in the understanding of the occurring process has to be evaluated.

High-resolution selective three-dimensional magnetic resonance coronary angiography with navigator-echo technique: segment-by-segment evaluation of coronary artery stenosis.

PURPOSE: To investigate the feasibility of high-resolution selective three-dimensional (3D) magnetic resonance coronary angiography (MRCA) in the evaluation of coronary artery stenoses. MATERIALS AND METHODS: In 12 patients with coronary artery stenoses, MRCA of the coronary artery groups, including the coronary segments with stenoses of 50% or greater based on conventional x-ray coronary angiography (CAG), was performed with double-oblique imaging planes by orienting the 3D slab along the major axis of each right coronary artery-left circumflex artery (RCA-LCX) group and each left main trunk-left anterior descending artery (LMT-LAD) group. Ten RCA-LCX and five LMT-LAD MR angiograms were obtained, and the results were compared with those of conventional x-ray angiography. RESULTS: Among 70 coronary artery segments expected to be covered, a total of 49 (70%) segments were fully demonstrated in diagnostic quality. The identification of segmental location of stenoses showed as high an accuracy as 96%. The retrospective analysis for stenosis of 50% or greater yielded the sensitivity, specificity, and accuracy of 80%, 85%, and 84%, respectively. CONCLUSION: Selective 3D MRCA has the potential for segment-by-segment evaluation of major portions of the right and left coronary arteries with high accuracy.

Anterior segment granuloma and optic nerve involvement as the presenting signs of systemic sarcoidosis.

PURPOSE: To report a case with anterior and posterior nodules associated with systemic sarcoidosis. METHODS: A patient with decreased vision underwent complete ophthalmologic examination, ultrasound biomicroscopy, fluorescein and indocyanine green (ICG) angiography. RESULTS: The patient presented a nodule of the iris of the OS and of the optic nerves of both eyes. Chest computed tomography and tissue biopsy established the diagnosis. CONCLUSIONS: Fluorescein and ICG angiography are the only objective exams to demonstrate the extent of ocular involvement in a patient with sarcoidosis.

Prefabrication of composite grafts for long-segment tracheal reconstruction.

OBJECTIVE: To investigate the prefabrication of vascularized mucosa-lined composite grafts intended to replace circumferential tracheal defects. DESIGN: Plane grafts composed of ear cartilage and full-thickness oral mucosa were revascularized by the laterothoracic fascia. The use of meshed vs nonmeshed mucosa to improve the epithelial coverage was examined. We also investigated the creation of a vascular bed over the cartilage and the subsequent application of meshed mucosa. Macroscopic aspects, viability, and degree of mucosal lining were analyzed. SUBJECTS: Twenty male New Zealand white rabbits. INTERVENTIONS: Ten animals underwent placement of auricular cartilage under the laterothoracic fascia. Intact (group 1) or meshed mucosa (group 2) was applied over the fascia and protected by a silicone sheet. After 3 weeks, prefabricated grafts were removed for comparison. In 10 other animals, a sheet of perforated cartilage was placed under the laterothoracic fascia. Two weeks later, 5 grafts (group 3) were harvested. The remaining 5 grafts were reopened for mucosal application over the cartilage and revascularized for 3 additional weeks (group 4). RESULTS: Vascularized plane grafts were obtained in all groups. Mucosal lining increased significantly with meshed mucosa (14%-68%; mean, 40%) compared with nonmeshed mucosa (3%-15%; mean, 10%) (P = .008). Induction of a vascular bed over perforated cartilage was achieved, but survival of secondary implanted mucosa was variable. CONCLUSIONS: A reliable technique to prefabricate composite grafts with cartilaginous support and mucosal lining is presented. The use of meshed mucosa significantly improves epithelial coverage.

Intérêt des faibles doses de rt-PA dans les syndromes inflammatoires et hémorragiques du segment antérieur: étude clinique et revue de la littérature [Treatment of anterior segment fibrinous reactions and hemorrhage with intracameral low dose rt-PA: clinical study and review of the literature].

PURPOSE: to evaluate the efficacy and the safety of low dose intraocular tissue plasminogen activator (rt-PA) in the treatment of traumatic hyphema and postoperative fibrinous membrane. METHODS: Six microg to 10 microg of rt-PA was injected into the anterior chamber to treat severe fibrinous postoperative membranes and total traumatic hyphemae. RESULTS: Thirteen eyes of 13 patients were treated. Four cases of traumatic hyphema and 9 cases of fibrinous membranes were included. Complete fibrinolysis within 24 hours was observed in 4 cases (30.8%). A partial success was noted in 7 eyes (53.8%). No beneficial effect was observed in two cases of traumatic hyphema associated with intravitreal hemorrhage after penetrating trauma. No side effect attributable to rt-PA occurred. CONCLUSION: Low dose intraocular rt-PA appears to be safe and effective in the treatment of postoperative fibrinous membrane and endocular hemorrhage limited to the anterior chamber.

Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar

RAPPORT DE SYNTHÈSE : Chez les patients présentant une pathologie de la colonne cervicale, l'instrumentation des voies aériennes peut s'avérer délicate. En effet, l'impossibilité d'effectuer une extension de la nuque afin d'aligner correctement l'axe oro-pharyngo-trachéal, ainsi que l'ouverture de bouche limitée par la présence d'une minerve cervicale, rendent la laryngoscopie standard extrêmement difficile. Le but de cette étude est de démontrer que l'intubation oro-trachéale avec une minerve cervicale semi-rigide est possible à l'aide d'un vidéolaryngoscope récemment développé, le GlideScope®. Celui-ci est formé d'une lame courbe présentant une angulation accentuée à 60° à partir de son milieu, avec une petite caméra haute résolution et une source lumineuse enchâssées dans la partie inférieure au point d'inflexion. Différents travaux ont montré les avantages du GlideScope® par rapport à la lame de Macintosh standard "pour l'instrumentation des voies aériennes de routine ou en situation difficile. Après acceptation par la Commission d'Ethique, 50 patients, adultes consentants et programmés pour une intervention chirurgicale élective nécessitant une anesthésie générale ont été inclus dans cette étude. Malgré la présence d'une minerve cervicale semi-rigide Philadelphia® Patriot correctement positionnée et la tête fixée à la table d'opération, tous les patients ont pu être intubés a l'aide du GlideScope®. Aucune complication n'a été documentée pendant la procédure ou en post-opératoire. De plus, nous avons démontré que dans cette situation la visualisation des structures laryngées est significativement améliorée grâce au GlideScope®, par rapport à la lame de Macintosh utilisée lors de toute intubation standard. En conclusion, l'intubation oro-trachéale chez les patients ayant une minerve cervicale et la tête fixée est possible à l'aide du GlideScope®. La meilleure façon de sécuriser les voies aériennes chez les patients présentant une instabilité de la colonne cervicale est un sujet fortement débattu. L'utilisation du GlideScope® pourrait s'avérer une alternative intéressante, en particulier dans les situations d'urgence.

Comparative effectiveness research across two spine registries.

BACKGROUND: Comparative effectiveness research in spine surgery is still a rarity. In this study, pain alleviation and quality of life (QoL) improvement after lumbar total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF) were anonymously compared by surgeon and implant. METHODS: A total of 534 monosegmental TDAs from the SWISSspine registry were analyzed. Mean age was 42 years (19-65 years), 59% were females. Fifty cases with ALIF were documented in the international Spine Tango registry and used as concurrent comparator group for the pain analysis. Mean age was 46 years (21-69 years), 78% were females. The average follow-up time in both samples was 1 year. Comparison of back/leg pain alleviation and QoL improvement was performed. Unadjusted and adjusted probabilities for achievement of minimum clinically relevant improvements of 18 VAS points or 0.25 EQ-5D points were calculated for each surgeon. RESULTS: Mean preoperative back pain decreased from 69 to 30 points at 1 year (ØΔ 39pts) after TDA, and from 66 to 27 points after ALIF (ØΔ 39pts). Mean preoperative QoL improved from 0.34 to 0.74 points at 1 year (ØΔ 0.40pts). There were surgeons with better patient selection, indicated by lower adjusted probabilities reflecting worsening of outcomes if they had treated an average patient sample. ALIF had similar pain alleviation than TDA. CONCLUSIONS: Pain alleviation after TDA and ALIF was similar. Differences in surgeon's patient selection based on pain and QoL were revealed. Some surgeons seem to miss the full therapeutic potential of TDA by selecting patients with lower symptom severity.

Lumbar spine texture enhances 10-year fracture probability assessment.

We found that lumbar spine texture analysis using trabecular bone score (TBS) is a risk factor for MOF and a risk factor for death in a retrospective cohort study from a large clinical registry for the province of Manitoba, Canada. INTRODUCTION: FRAX® estimates the 10-year probability of major osteoporotic fracture (MOF) using clinical risk factors and femoral neck bone mineral density (BMD). Trabecular bone score (TBS), derived from texture in the spine dual X-ray absorptiometry (DXA) image, is related to bone microarchitecture and fracture risk independently of BMD. Our objective was to determine whether TBS provides information on MOF probability beyond that provided by the FRAX variables. METHODS: We included 33,352 women aged 40-100 years (mean 63 years) with baseline DXA measurements of lumbar spine TBS and femoral neck BMD. The association between TBS, the FRAX variables, and the risk of MOF or death was examined using an extension of the Poisson regression model. RESULTS: During the mean of 4.7 years, 1,754 women died and 1,872 sustained one or more MOF. For each standard deviation reduction in TBS, there was a 36 % increase in MOF risk (HR 1.36, 95 % CI 1.30-1.42, p < 0.001) and a 32 % increase in death (HR 1.32, 95 % CI 1.26-1.39, p < 0.001). When adjusted for significant clinical risk factors and femoral neck BMD, lumbar spine TBS was still a significant predictor of MOF (HR 1.18, 95 % CI 1.12-1.23) and death (HR 1.20, 95 % CI 1.14-1.26). Models for estimating MOF probability, accounting for competing mortality, showed that low TBS (10th percentile) increased risk by 1.5-1.6-fold compared with high TBS (90th percentile) across a broad range of ages and femoral neck T-scores. CONCLUSIONS: Lumbar spine TBS is able to predict incident MOF independent of FRAX clinical risk factors and femoral neck BMD even after accounting for the increased death hazard.

Efficacy And Safety Of Baerveldt Aqueous Shunts In Glaucoma Secondary To Anterior Segment Irradiation, For Uveal Melanoma

Purpose: Elevated IOP is commonly associated with iris and ciliary body melanoma. Traditional management requires the majority of eyes to undergo enucleation. The authors describe the first series of Baerveldt aqueous shunts in eyes with uveal melanoma, treated by total anterior segment irradiation.Methods: 25 consecutive patients with unilateral iris melanoma were prospectively recruited after obtaining informed consent. All patients underwent anterior segment proton beam irradiation, corneal limbal autografts and Baerveldt tube implantation at Jules Gonin Eye Hospital, Lausanne. Postoperative examinations were performed on day 1, weeks 1,3,6,9 and months 3,6,12 and annually thereafter. Success was defined as: IOP </=18mmHg (definition A); IOP </= 21mmHg and 20% reduction in IOP (definition B). All complications were recorded.Results: Mean age was 53; mean follow up, 10.3 months; mean interval to treatment following irradiation, 2.4 years; mean pre-op IOP was 29.9 mmHg; mean post-op IOP 14.1 mmHg; mean pre-op medications 3.0; post-op medications 1.3. Success rates were, definition A: 95%; definition B: 90%. Only11% had minor complications and there were no sight-threatening complications. Aggressive ocular hypertension was observed in the several eyes prior to shunt implantation. Two eyes were enucleated for non-glaucoma related sequelae.Conclusions: Baerveldt aqueous shunts are safe and efficacious following total anterior segment irradiation for uveal melanoma. The novel interdisciplinary approach improved ocular retention rates, offering a promising alternative to current management algorithms.