Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke.

OBJECTIVE: We examined the influence of clinical, radiologic, and echocardiographic characteristics on antithrombotic choice in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), hypothesizing that features suggestive of paradoxical embolism might lead to greater use of anticoagulation. METHODS: The Risk of Paradoxical Embolism Study combined 12 databases to create the largest dataset of patients with CS and known PFO status. We used generalized linear mixed models with a random effect of component study to explore whether anticoagulation was preferentially selected based on the following: (1) younger age and absence of vascular risk factors, (2) "high-risk" echocardiographic features, and (3) neuroradiologic findings. RESULTS: A total of 1,132 patients with CS and PFO treated with anticoagulation or antiplatelets were included. Overall, 438 participants (39%) were treated with anticoagulation with a range (by database) of 22% to 54%. Treatment choice was not influenced by age or vascular risk factors. However, neuroradiologic findings (superficial or multiple infarcts) and high-risk echocardiographic features (large shunts, shunt at rest, and septal hypermobility) were predictors of anticoagulation use. CONCLUSION: Both antithrombotic regimens are widely used for secondary stroke prevention in patients with CS and PFO. Radiologic and echocardiographic features were strongly associated with treatment choice, whereas conventional vascular risk factors were not. Prior observational studies are likely to be biased by confounding by indication.

Oxidative stress in gastric mucosa of asymptomatic humans infected with Helicobacter pylori: effect of bacterial eradication.

BACKGROUND: Inducible nitric oxide synthase (iNOS) and interleukin 8 (IL-8) are positive in approximately 50% of Helicobacter pylori-related diseases but it is not clear whether oxidative stress is also present in H. pylori asymptomatic humans. Our aim was to study the expression of iNOS, superoxide dismutase, catalase and IL-8 production in H. pylori-infected asymptomatic humans, and to investigate the effect of eradication of H. pylori. MATERIALS AND METHODS: Biopsies of corpus and antrum of asymptomatic H. pylori positive and negative humans served for determination of the gastritis score and H. pylori status; iNOS was measured by reverse transcriptase polymerase chain reaction and immunohistochemistry and superoxide dismutase and catalase by immunohistochemistry. IL-8 in biopsies was assessed by enzyme-linked immunosorbent assay. RESULTS: Immunostaining of iNOS, catalase and superoxide dismutase was significantly associated with H. pylori infection and was localized to inflammatory cells. IL-8 concentrations were greater in the H. pylori positive than H. pylori negative group and decreased after bacterial eradication. A decrease in staining for iNOS and catalase was observed after H. pylori eradication. CONCLUSIONS: INOS and antioxidant enzymes are present in gastric biopsies of asymptomatic H. pylori positive humans. Eradication caused a significant decrease in staining for iNOS and catalase. These results indicate that oxidative stress occurs in asymptomatic patients and can be modulated by H. pylori eradication.

Dix ans de revue de la littérature en médecine interne générale--un premier bilan [Ten years of literature review in general internal medicine--a first assessment].

A group of family physicians in an outpatient clinic in Switzerland prospectively followed scientific literature for ten years. What to remember among the numerous articles retrieved and which paper really changed our practice? If many readings are quickly forgotten, some of them marked our minds and changed our habits. This article is a summary of our efforts to keep the essential tools in clinical practice.

Right ventricular rupture due to recurrent mediastinal infection with a closed chest.

Right ventricular (RV) rupture in cases of mediastinitis following cardiac surgery is a rare and dangerous complication. Bleeding from the right ventricle occurs mainly after sternal reopening, due to either iatrogenic manipulation (wire removal, lesions due to wiring maneuvers) or mechanical shearing forces, producing direct injury. We present a case of RV wall perforation due to infection in a recurrent postoperative mediastinitis with a closed chest. The current literature on treatment of postoperative mediastinitis is also reviewed.

Acute Hepatitis E Virus infection with coincident reactivation of Epstein-Barr virus infection in an immunosuppressed patient with rheumatoid arthritis: a case report.

BACKGROUND: Hepatitis E virus (HEV) is the most recently discovered of the hepatotropic viruses, and is considered an emerging pathogen in developed countries with the possibility of fulminant hepatitis in immunocompromised patients. Especially in the latter elevated transaminases should be taken as a clue to consider HEV infection, as it can be treated by discontinuation of immunosuppression and/or ribavirin therapy. To our best knowledge, this is a unique case of autochthonous HEV infection with coincident reactivation of Epstein-Barr virus (EBV) infection in an immunosuppressed patient with rheumatoid arthritis (RA). CASE PRESENTATION: A 68-year-old Swiss woman with RA developed hepatitis initially diagnosed as methotrexate-induced liver injury, but later diagnosed as autochthonous HEV infection accompanied by reactivation of her latent EBV infection. She showed confounding serological results pointing to three hepatotropic viruses (HEV, Hepatitis B virus (HBV) and EBV) that could be resolved by detection of HEV and EBV viraemia. The patient recovered by temporary discontinuation of immunosuppressive therapy. CONCLUSIONS: In immunosuppressed patients with RA and signs of liver injury, HEV infection should be considered, as infection can be treated by discontinuation of immunosuppression. Although anti-HEV-IgM antibody assays can be used as first line virological tools, nucleic acid amplification tests (NAAT) for detection of HEV RNA are recommended--as in our case--if confounding serological results from other hepatotropic viruses are obtained. After discontinuation of immunosuppressive therapy, our patient recovered from both HEV infection and reactivation of latent EBV infection without sequelae.

Accélération de la guérison fracturaire par le tériparatide: série de 22 cas et revue de la littérature [Improvement of fracture healing with teriparatide: series of 22 cases and review of the literature].

La pseudarthrose est définie comme une fracture qui ne guérit pas sans intervention additionnelle neuf mois après le traumatisme et en l'absence de progression radiologique pendant les trois derniers mois. Les fractures ostéoporotiques sont à plus grand risque de complications chirurgicales. On se pose de plus en plus souvent la question d'ajouter un traitement médicamenteux pour accélérer le processus de guérison fracturaire. Il existe des données montrant que le tériparatide (anabolisant osseux issu de l'hormone parathyroïdienne) accélère la guérison osseuse et améliore le devenir fonctionnel, avec ou sans chirurgie, dans des situations de fractures typiques ou atypiques. Les risques liés à ce traitement sont faibles, mais la prescription nécessite l'accord de l'assurance-maladie dans cette indication. Nous rapportons notre expérience sur l'utilisation de cette molécule, hors indication officielle, dans des cas complexes de non-guérison fracturaire. Pseudoarthrosis is defined as a non healing fracture 9 months after trauma and without radiological progression within the last three months. Osteoporotic fractures have a greater risk of chirurgical complications. The question of giving a medical treatment in the purpose of accelerating fracture healing is an increasing concern. There are data showing that with teriparatide (bone anabolic treatment derived from the parathyroid hormone) bone healing and functional status are improved, with or without surgery, in the case of either typical or atypical fractures. The risks of this treatment are low but health insurance agreement is needed in this indication. We report our experience with the use of this molecule, out of the official indication, in complex situations of non healing fractures.

Diverticulites sigmoïdiennes aiguës: vers un traitement de plus en plus conservateur [Acute sigmoid diverticulitis: toward a more and more conservative treatment].

La diverticulite colique aiguë est une pathologie fréquente en particulier chez les personnes âgées et d'origine caucasienne. La prévalence est plus importante chez les sédentaires et les personnes ayant un régime comprenant peu de fibres. Son diagnostic se base principalement sur la tomodensitométrie (CT) qui permet d'orienter la prise en charge thérapeutique. Ces dernières années, le traitement de la diverticulite aiguë a passablement changé avec notamment une évolution vers une restriction des indications du traitement chirurgical électif ou en urgence et une désescalade thérapeutique, avec réduction de l'antibiothérapie et du nombre d'hospitalisations. Cet article passe en revue l'épidémiologie, les moyens diagnostiques et la prise en charge de cette pathologie digestive courante. Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.

L'infundibulite, une cause rare (?) de diabète insipide central [Infundibulitis, an unusual case of central diabetes insipidus].

We report the case of a 53 year old patient who was admitted with polyuria, polydipsia associated with fatigue, depression and sexual dysfunction. Central diabetes insipidus with hypogonadotrophic hypogonadism was diagnosed by a water restriction test and different static and dynamic hormonal dosages. Nodular thickening of the pituitary stalk was noted on the MRI and the biopsy permitted a histological diagnosis of infundibulitis.

Differences in pandemic influenza vaccination policies for pregnant women in Europe.

BACKGROUND: An important component of the policy to deal with the H1N1 pandemic in 2009 was to develop and implement vaccination. Since pregnant women were found to be at particular risk of severe morbidity and mortality, the World Health Organization and the European Centers for Disease Control advised vaccinating pregnant women, regardless of trimester of pregnancy. This study reports a survey of vaccination policies for pregnant women in European countries. METHODS: Questionnaires were sent to European competent authorities of 27 countries via the European Medicines Agency and to leaders of registries of European Surveillance of Congenital Anomalies in 21 countries. RESULTS: Replies were received for 24 out of 32 European countries of which 20 had an official pandemic vaccination policy. These 20 countries all had a policy targeting pregnant women. For two of the four countries without official pandemic vaccination policies, some vaccination of pregnant women took place. In 12 out of 20 countries the policy was to vaccinate only second and third trimester pregnant women and in 8 out of 20 countries the policy was to vaccinate pregnant women regardless of trimester of pregnancy. Seven different vaccines were used for pregnant women, of which four contained adjuvants. Few countries had mechanisms to monitor the number of vaccinations given specifically to pregnant women over time. Vaccination uptake varied. CONCLUSIONS: Differences in pandemic vaccination policy and practice might relate to variation in perception of vaccine efficacy and safety, operational issues related to vaccine manufacturing and procurement, and vaccination campaign systems. Increased monitoring of pandemic influenza vaccine coverage of pregnant women is recommended to enable evaluation of the vaccine safety in pregnancy and pandemic vaccination campaign effectiveness.

Soins palliatifs en établissements médico-sociaux: Caractéristiques et spécificités [Palliative Care in Nursing Homes: Characteristics and Specificities].

Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.

A probable dual mode of action for both L- and D-lactate neuroprotection in cerebral ischemia.

Lactate has been shown to offer neuroprotection in several pathologic conditions. This beneficial effect has been attributed to its use as an alternative energy substrate. However, recent description of the expression of the HCA1 receptor for lactate in the central nervous system calls for reassessment of the mechanism by which lactate exerts its neuroprotective effects. Here, we show that HCA1 receptor expression is enhanced 24 hours after reperfusion in an middle cerebral artery occlusion stroke model, in the ischemic cortex. Interestingly, intravenous injection of L-lactate at reperfusion led to further enhancement of HCA1 receptor expression in the cortex and striatum. Using an in vitro oxygen-glucose deprivation model, we show that the HCA1 receptor agonist 3,5-dihydroxybenzoic acid reduces cell death. We also observed that D-lactate, a reputedly non-metabolizable substrate but partial HCA1 receptor agonist, also provided neuroprotection in both in vitro and in vivo ischemia models. Quite unexpectedly, we show D-lactate to be partly extracted and oxidized by the rodent brain. Finally, pyruvate offered neuroprotection in vitro whereas acetate was ineffective. Our data suggest that L- and D-lactate offer neuroprotection in ischemia most likely by acting as both an HCA1 receptor agonist for non-astrocytic (most likely neuronal) cells as well as an energy substrate.

Effect of Cumulating Exposure to Abacavir on the Risk of Cardiovascular Disease Events in Patients From the Swiss HIV Cohort Study.

BACKGROUND: Patients with HIV exposed to the antiretroviral drug abacavir may have an increased risk of cardiovascular disease (CVD). There is concern that this association arises because of a channeling bias. Even if exposure is a risk, it is not clear how that risk changes as exposure cumulates. METHODS: We assess the effect of exposure to abacavir on the risk of CVD events in the Swiss HIV Cohort Study. We use a new marginal structural Cox model to estimate the effect of abacavir as a flexible function of past exposures while accounting for risk factors that potentially lie on a causal pathway between exposure to abacavir and CVD. RESULTS: A total of 11,856 patients were followed for a median of 6.6 years; 365 patients had a CVD event (4.6 events per 1000 patient-years). In a conventional Cox model, recent--but not cumulative--exposure to abacavir increased the risk of a CVD event. In the new marginal structural Cox model, continued exposure to abacavir during the past 4 years increased the risk of a CVD event (hazard ratio = 2.06; 95% confidence interval: 1.43 to 2.98). The estimated function for the effect of past exposures suggests that exposure during the past 6-36 months caused the greatest increase in risk. CONCLUSIONS: Abacavir increases the risk of a CVD event: the effect of exposure is not immediate, rather the risk increases as exposure cumulates over the past few years. This gradual increase in risk is not consistent with a rapidly acting mechanism, such as acute inflammation.