Vitamin D levels and associated factors: a population-based study in Switzerland.

QUESTIONS UNDER STUDY: To update the prevalence of vitamin D insufficiency and to identify factors associated with vitamin D status in the Swiss adult population. METHODS: Data from the 2010-2011 Swiss Study on Salt intake, a population-based study in the Swiss population, was used. Vitamin D concentration in serum was measured by liquid chromatography- tandem mass spectrometry. Major factors that influence vitamin D levels were taken into account. Survey statistical procedures were used to estimate means and prevalences of vitamin D levels and status. Monthly-specific tertiles of vitamin D and ordinal logistic regression were used to determine the associations of covariates of interest with vitamin D status. RESULTS: The prevalences of vitamin D insufficiency (serum 25-hydroxyvitamin D: 20-29.9 ng/ml) and deficiency (<20 ng/ml) were the highest in the January-March period; 26.4% (95%CI: 21.6-31.7) and 61.6% (95%CI: 56.0-67.0), respectively. In the same period, more than 9 of ten men were vitamin D insufficient or deficient. Each unit increase of Body Mass Index was associated with an 8% decreased likelihood of being in a higher vitamin D tertiles. Oral contraceptive, altitude, urinary excretion of calcium, use of vitamin D supplement or treatment, high wine consumption, physical activity were associated with vitamin D tertiles. Compared to the French-speaking region, the Italian-speaking region was independently associated with a higher likelihood of being in higher vitamin D tertiles (OR: 1.66, 95%CI: 1.14-2.43). CONCLUSIONS: Low levels of vitamin D are common among Swiss adults, in particular during winter months and outside the Italian-speaking region.

Recessive multiple epiphyseal dysplasia (rMED) with homozygosity for C653S mutation in the DTDST gene - phenotype, molecular diagnosis and surgical treatment of habitual dislocation of multilayered patella: case report.

BACKGROUND: Multiple epiphyseal dysplasia (MED) is one of the more common generalised skeletal dysplasias. Due to its clinical heterogeneity diagnosis may be difficult. Mutations of at least six separate genes can cause MED. Joint deformities, joint pain and gait disorders are common symptoms. CASE PRESENTATION: We report on a 27-year-old male patient suffering from clinical symptoms of autosomal recessive MED with habitual dislocation of a multilayered patella on both sides, on the surgical treatment and on short-term clinical outcome. Clinical findings were: bilateral hip and knee pain, instability of femorotibial and patellofemoral joints with habitual patella dislocation on both sides, contractures of hip, elbow and second metacarpophalangeal joints. Main radiographic findings were: bilateral dislocated multilayered patella, dysplastic medial tibial plateaus, deformity of both femoral heads and osteoarthritis of the hip joints, and deformity of both radial heads. In the molecular genetic analysis, the DTDST mutation g.1984T > A (p.C653S) was found at the homozygote state. Carrier status was confirmed in the DNA of the patient's parents. The mutation could be considered to be the reason for the patient's disease. Surgical treatment of habitual patella dislocation with medialisation of the tibial tuberosity led to an excellent clinical outcome. CONCLUSIONS: The knowledge of different phenotypes of skeletal dysplasias helps to select genes for genetic analysis. Compared to other DTDST mutations, this is a rather mild phenotype. Molecular diagnosis is important for genetic counselling and for an accurate prognosis. Even in case of a multilayered patella in MED, habitual patella dislocation could be managed successfully by medialisation of the tibial tuberosity.

SPECT myocardial perfusion imaging: long-term prognostic value in diabetic patients with and without coronary artery disease.

AIM: To determine the long-term prognostic value of SPECT myocardial perfusion imaging (MPI) for the occurrence of cardiovascular events in diabetic patients. PATIENTS, METHODS: SPECT MPI of 210 consecutive Caucasian diabetic patients were analysed using Kaplan-Meier event-free survival curves and independent predictors were determined by Cox multivariate analyses. RESULTS: Follow-up was complete in 200 (95%) patients with a median period of 3.0 years (0.8-5.0). The population was composed of 114 (57%) men, age 65 +/- 10 years, 181 (90.5%) type 2 diabetes mellitus, 50 (25%) with a history of coronary artery disease (CAD) and 98 (49%) presenting chest pain prior to MPI. The prevalence of abnormal MPI was 58%. Patients with a normal MPI had neither cardiac death, nor myocardial infarction, independently of a history of coronary artery disease or chest pain. Among the independent predictors of cardiac death and myocardial infarction, the strongest was abnormal MPI (p < 0.0001), followed by history of CAD (Hazard Ratio (HR) = 15.9; p = 0.0001), diabetic retinopathy (HR = 10.0; p = 0.001) and inability to exercise (HR = 7.7; p = 0.02). Patients with normal MPI had a low revascularisation rate of 2.4% during the follow-up period. Compared to normal MPI, cardiovascular events increased 5.2 fold for reversible defects, 8.5 fold for fixed defects and 20.1 fold for the association of both defects. CONCLUSION: Diabetic patients with normal MPI had an excellent prognosis independently of history of CAD. On the opposite, an abnormal MPI led to a >5-fold increase in cardiovascular events. This emphasizes the value of SPECT MPI in predicting and risk-stratifying cardiovascular events in diabetic patients.

Outcome following percutaneous transluminal coronary angioplasty performed before 1990.

The goal of this follow-up study was to assess the long-term survival of all patients having undergone a first PTCA between 1981 and 1990 and to relate the outcome to the baseline clinical and angiographic state. Although PTCA has become a widely accepted therapeutic choice for revascularization, the authors lacked information on long-term outcome. Data was collected by questionnaire, the end points being a second PTCA, MI, CABG, death or any of these events. The survival curves were constructed using the Kaplan-Meier method. Multivariate analysis was performed by a Cox proportional hazards model. Complete follow-up data were collected for 1,071 patients for a mean period of 7.4 years (SEM +/- 1.98 months) with a range of 0 to 14 years. Mean age was 57 years. PTCA was successful in 85% of patients. In-hospital event rates were death 1.3%, MI 4.4%, and emergency CABG 2.9%. Overall survival at 14 years was 69% (SEM +/- 9.6%) and event-free survival was 47% (SEM +/- 5.8%). MI rate was 11%, CABG 15%, and 20% of patients underwent repeat PTCA. Presence of cardiovascular risk factors, poor left ventricular ejection fraction, and prior CABG were significantly associated with poorer event-free survival. The short-term observations are consistent with results reported by the other follow-up studies. In addition, the study found a total survival rate 14 years after a first PTCA of 69% and 47% of the cohort remained event free.

Approche hybride chirurgicale et endovasculaire lors d'artériopathie périphérique oblitérante multiétagée des membres inférieurs

Contexte : La prise en charge de l'artériopathie périphérique et de l'ischémie critique a fortement évolué depuis plusieurs années en faveur des traitements endovasculaires. En effet, la revascularisation chirurgicale a prouvé son efficacité à moyen et long terme mais reste invasif avec un temps de séjour hospitalier prolongé. Plusieurs études ont démontré l'intérêt de la prise en charge endovasculaire afin de réduire la morbidité et diminuer la durée de séjour. Néanmoins, elle n'offre pas des taux de succès à moyen et long terme équivalent à la chirurgie. Une approche hybride chirurgicale et endovasculaire cherchant à utiliser les avantages des 2 techniques pourrait permettre d'obtenir des taux de succès élevé avec un taux de complication plus faible. Objectifs : Nos objectifs sont d'analyser rétrospectivement la population de patients ayant bénéficié d'une approche hybride pour la revascularisation des membres inférieurs pour une claudication intermittente ou une ischémie critique. Le taux de mortalité à 30 jours ainsi que les complications locales et systémiques seront relevés. Les taux de perméabilité à 12 mois seront également analysés. Finalement, le taux de sauvetage de membre ainsi que le pourcentage de déambulation seront reportés. Méthodes : La cohorte de patients ayant bénéficié d'une approche hybride dans le service de chirurgie thoracique et vasculaire du CHUV de janvier 2008 à janvier 2011 seront systématiquement inclus dans l'analyse. L'ensemble des données démographiques et angiologiques seront reportés dans un cahier d'observation. De plus, tous les événements liés à des complications locales ou systémiques seront également analysés. Les décès seront reportés. Un appel téléphonique au patient et à son médecin traitant permettra de connaître l'état de santé actuel du patient ainsi que sa capacité à la marche. Une analyse statistique comportant une courbe de survivre selon Kaplan Meier permettra d'analyser le taux de perméabilité ainsi que la survie à moyen terme. Résultats escomptés : Les résultats devraient nous démontrés un taux de perméabilité supérieur ou équivalent à la prise en charge séparée chirurgicale ou endovasculaire. De plus les complications locales devraient être inférieures au taux obtenus dans la prise en charge chirurgicale. Le taux de sauvetage de membre et de déambulation pourrait être identique à la prise en charge chirurgicale. Plus value escomptés : L'approche hybride pour la revascularisation des membres inférieurs reste peu décrite dans la littérature. Cette étude permettra de décrire de manière globale une grande cohorte de patients homogène ayant bénéficié de cette approche dans un seul centre. Elle démontrera aussi l'éventuel intérêt de ce type de prise en charge pour les patients souffrant d'une artériopathie périphérique multiétagée.

A epidemiologia como referencial teórico-metodológico no processo de trabalho do enfermeiro

Esta reflexão teve como objetivo compreender a Epidemiologia como referencial teórico-metodológico para a prática da Enfermagem em Saúde Coletiva. O método de pesquisa foi uma investigação bibliográfica, com a análise de artigos e livros de estudiosos que apontam as possibilidades e limites das Epidemiologias clássica, social e crítica, com intuito de aproximar suas concepções à prática do enfermeiro. Discute-se que a articulação dos conhecimentos advindos das supracitadas visões de Epidemiologia possibilita a construção de intervenções de Enfermagem para a transformação de realidades de saúde. A Epidemiologia Crítica ampara-se no reconhecimento dos processos protetores e de desgastes determinantes do processo saúde-doença vividos por grupos de classes sociais distintas. Assim, cabe ao enfermeiro planejar a intervenção em saúde para além do adoecimento identificado, propondo intervenções comprometidas com a mudança de processos históricos e sociais, nas dimensões singular, particular ou estrutural, que acabam por determinar o processo saúde-doença em indivíduos ou grupos.

ECG interpretation during the acute phase of coronary syndromes: in need of improvement?

QUESTION UNDER STUDY: Emergency room (ER) interpretation of the ECG is critical to assessment of patients with acute coronary syndromes (ACS). Our aim was to assess its reliability in our institution, a tertiary teaching hospital. METHODS: Over a 6-month period all consecutive patients admitted for ACS were included in the study. ECG interpretation by emergency physicians (EPs) was recorded on a preformatted sheet and compared with the interpretation of two specialist physicians (SPs). Discrepancies between the 2 specialists were resolved by an ECG specialist. RESULTS: Over the 6-month period, 692 consecutive patients were admitted with suspected ACS. ECG interpretation was available in 641 cases (93%). Concordance between SPs was 87%. Interpretation of normality or abnormality of the ECG was concordant between EPs and SPs in 475 cases (74%, kappa = 0.51). Interpretation of ischaemic modifications was concordant in 69% of cases, and as many ST segment elevations were unrecognised as overdiagnosed (5% each). The same findings occurred for ST segment depressions and negative T waves (12% each). CONCLUSIONS: Interpretation of the ECG recorded during ACS by 2 SPs was discrepant in 13% of cases. Similarly, EP interpretation was discrepant from SP interpretation in 25% of cases, equally distributed between over- and underdiagnosing of ischaemic changes. The clinical implications and impact of medical education on ECG interpretation require further study.

Hospital Amigo da Criança: prevalência de aleitamento materno exclusivo aos seis meses e fatores intervenientes

O objetivo da pesquisa foi identificar o padrão de aleitamento materno exclusivo nos primeiros seis meses de vida de crianças nascidas em um Hospital Amigo da Criança e os fatores que contribuíram para o desmame precoce. Estudo de coorte prospectivo com 261 mães e crianças. Os dados foram avaliados utilizando-se a análise de sobrevivência através da construção da curva de Kaplan-Meier e teste de Log-Rank para a análise univariada. Foi realizada análise multivariada utilizando-se o modelo de Regressão de Cox com riscos proporcionais. Ao longo dos seis meses, o aleitamento materno exclusivo praticado com 30, 90, 120, 150 e 180 dias foi 75%, 52%, 33%, 19% e 5,7%, respectivamente. Na análise multivariada, as variáveis que mostraram risco para o desmame precoce foram a intercorrência mamária hospitalar e, na consulta de retorno, a posição inadequada e a associação das duas anteriores. A Iniciativa Hospital Amigo da Criança favoreceu o aleitamento materno exclusivo.

Biotic and abiotic variables show little redundancy in explaining tree species distributions

Abiotic factors such as climate and soil determine the species fundamental niche, which is further constrained by biotic interactions such as interspecific competition. To parameterize this realized niche, species distribution models (SDMs) most often relate species occurrence data to abiotic variables, but few SDM studies include biotic predictors to help explain species distributions. Therefore, most predictions of species distributions under future climates assume implicitly that biotic interactions remain constant or exert only minor influence on large-scale spatial distributions, which is also largely expected for species with high competitive ability. We examined the extent to which variance explained by SDMs can be attributed to abiotic or biotic predictors and how this depends on species traits. We fit generalized linear models for 11 common tree species in Switzerland using three different sets of predictor variables: biotic, abiotic, and the combination of both sets. We used variance partitioning to estimate the proportion of the variance explained by biotic and abiotic predictors, jointly and independently. Inclusion of biotic predictors improved the SDMs substantially. The joint contribution of biotic and abiotic predictors to explained deviance was relatively small (similar to 9%) compared to the contribution of each predictor set individually (similar to 20% each), indicating that the additional information on the realized niche brought by adding other species as predictors was largely independent of the abiotic (topo-climatic) predictors. The influence of biotic predictors was relatively high for species preferably growing under low disturbance and low abiotic stress, species with long seed dispersal distances, species with high shade tolerance as juveniles and adults, and species that occur frequently and are dominant across the landscape. The influence of biotic variables on SDM performance indicates that community composition and other local biotic factors or abiotic processes not included in the abiotic predictors strongly influence prediction of species distributions. Improved prediction of species' potential distributions in future climates and communities may assist strategies for sustainable forest management.

Cytogenetic response to imatinib in chronic myeloid leukaemia patients: concentration dependency and associated influences under field-conditions

Introduction: Imatinib, a first-line drug for chronic myeloid leukaemia (CML), has been increasingly proposed for therapeutic drug monitoring (TDM), as trough concentrations >=1000 ng/ml (Cmin) have been associated with improved molecular and complete cytogenetic response (CCyR). The pharmacological monitoring project of EUTOS (European Treatment and Outcome Study) was launched to validate retrospectively the correlation between Cmin and response in a large population of patients followed by central TDM in Bordeaux.¦Methods: 1898 CML patients with first TDM 0-9 years after imatinib initiation, providing cytogenetic data along with demographic and comedication (37%) information, were included. Individual Cmin, estimated by non-linear regression (NONMEM), was adjusted to initial standard dose (400 mg/day) and stratified at 1000 ng/ml. Kaplan-Meier estimates of overall cumulative CCyR rates (stratified by sex, age, comedication and Cmin) were compared using asymptotic logrank k-sample test for interval-censored data. Differences in Cmin were assessed by Wilcoxon test.¦Results: There were no significant differences in overall cumulative CCyR rates between Cmin strata, sex and comedication with P-glycoprotein inhibitors/inducers or CYP3A4 inhibitors (p >0.05). Lower rates were observed in 113 young patients <30 years (p = 0.037; 1-year rates: 43% vs 60% in older patients), as well as in 29 patients with CYP3A4 inducers (p = 0.001, 1-year rates: 40% vs 66% without). Higher rates were observed in 108 patients on organic-cation-transporter-1 (hOCT-1) inhibitors (p = 0.034, 1-year rates: 83% vs 56% without). Considering 1-year CCyR rates, a trend towards better response for Cmin above 1000 ng/ml was observed: 64% (95%CI: 60-69%) vs 59% (95%CI: 56-61%). Median Cmin (400 mg/day) was significantly reduced in male patients (732 vs 899ng/ml, p <0.001), young patients <30 years (734 vs 802 ng/ml, p = 0.037) and under CYP3A4 inducers (758 vs 859 ng/ml, p = 0.022). Under hOCT-1 inhibitors, Cmin was increased (939 vs 827 ng/ml, p = 0.038).¦Conclusion: Based on observational TDM data, the impact of imatinib Cmin >1000 ng/ml on CCyR was not salient. Young CML patients (<30 years) and patients taking CYP3A4 inducers probably need close monitoring and possibly higher imatinib doses, due to lower Cmin along with lower CCyR rates. Patients taking hOCT-1 inhibitors seem in contrast to have improved CCyR response rates. The precise role for imatinib TDM remains to be established prospectively.

La néphropathie ischémique par athérosclérose aortorénale : diagnostic [Atherosclerotic renal artery disease diagnosis update].

Atherosclerotic renal artery disease represents a cause of which little is known but not a cause to be neglected for hypertension and renal insufficiency. Even though its occurrence remains badly defined, atherosclerotic renal artery disease is constantly on the rise due to the aging population, the never prevailing hypertension and diabetes mellitus. This review aims to give a clinical profile of patients presenting with atherosclerotic renal artery disease and to discuss, in the light of study results, which diagnostic evaluation should be used considering the sequence and the benefit and risk of each in order to initiate a personalized treatment. Patients affected by atherosclerotic renal artery disease are likely to have more complications and more extensive target-organ damage than patients without renal artery stenosis. The evolution of the atherosclerotic renal artery disease is in general slow and progressive. Nevertheless, certain clinical cases manifest themselves with the onset of acute renal failure bought upon by the administration of blockers of the rennin-angiotensin-aldosterone system, or by some other causes responsible for a sudden drop in renal plasma flow (e.g., thrombosis of the renal artery). The relationship between atherosclerotic renal artery disease and atherosclerosis is complex, and mediators implicated in the pathophysiology of renovascular disease may also contribute to the progression of cardiovascular damage. An early assumption of the atherosclerotic renal artery stenosis is warranted to determine the adapted treatment (i.e., medical treatment, revascularisation...) just as the assumption and the correction of the more general cardiovascular risk factors.