C'est le moment où ressurgissent les rêves

Interview. Pasqualina Perrig-Chiello étudie depuis des années le développement des gens qui se trouvent au milieu de leur vie, entre 40 et 60 ans.

Percutaneous closure of patent foramen ovale in patients with cryptogenic embolism: a network meta-analysis

BACKGROUND Up to 40% of ischaemic strokes are cryptogenic. A strong association between cryptogenic stroke and the prevalence of patent foramen ovale (PFO) suggests paradoxical embolism via PFO as a potential cause. Randomized trials failed to demonstrate superiority of PFO closure over medical therapy. METHODS AND RESULTS Randomized trials comparing percutaneous PFO closure against medical therapy or devices head-to-head published or presented by March 2013 were identified through a systematic search. We performed a network meta-analysis to determine the effectiveness and safety of PFO closure with different devices when compared with medical therapy. We included four randomized trials (2963 patients with 9309 patient-years). Investigated devices were Amplatzer (AMP), STARFlex (STF), and HELEX (HLX). Patients allocated to PFO closure with AMP were less likely to experience a stroke than patients allocated to medical therapy [rate ratio (RR) 0.39; 95% CI: 0.17-0.84]. No significant differences were found for STF (RR 1.01; 95% CI: 0.44-2.41), and HLX (RR, 0.71; 95% CI: 0.17-2.78) when compared with medical therapy. The probability to be best in preventing strokes was 77.1% for AMP, 20.9% for HLX, 1.7% for STF, and 0.4% for medical therapy. No significant differences were found for transient ischaemic attack and death. The risk of new-onset atrial fibrillation was more pronounced for STF (RR 7.67; 95% CI: 3.25-19.63), than AMP (RR 2.14; 95% CI: 1.00-4.62) and HLX (RR 1.33; 95%-CI 0.33-4.50), when compared with medical therapy. CONCLUSIONS The effectiveness of PFO closure depends on the device used. PFO closure with AMP appears superior to medical therapy in preventing strokes in patients with cryptogenic embolism.

A propensity score-matched comparison between Cardia and Amplatzer PFO closure devices - insights from the SOLUTION registry (Swiss percutaneOus patent foramen ovale cLosUre in recurrent clinical events prevenTION)

Aims: To compare clinical outcome of Amplatzer PFO (APFO) to Cardia PFO (CPFO) occluder. Percutaneous patent foramen ovale (PFO) closure prevents stroke recurrence in stroke due to paradoxical embolism. Methods and results: The primary endpoint was a composite of stroke, TIA, or peripheral embolism at follow-up. The secondary endpoint was residual shunt. Outcome was compared among 934 (APFO: 712; CPFO: 222) patients, and in 297 propensity score-matched patients. The primary endpoint occurred in 29 patients (0.71/100 patient-years): four (2%) with the CPFO (0.31/100 patient-years), and 25 (4%) with the APFO (0.89/100 patient-years) (p=0.20). Residual shunt at six months was more frequent with the CPFO (31% versus 9%, p<0.001). No differences in residual shunts were seen at the last available echocardiographic follow-up (9±18 months): APFO 11%, CPFO 14%, p=0.22. Conclusions: This study suggests that PFO closure with APFO or CPFO is equally effective for the prevention of recurrent events. Residual shunt was more frequent at six months with CPFO, but was similar to APFO at later follow-up.

Speech outcome in complete unilateral cleft lip and palate - a comparison of three methods of the hard palate closure.

The aim of this study was to compare the speech in subjects with cleft lip and palate, in whom three methods of the hard palate closure were used. One hundred and thirty-seven children (96 boys, 41 girls; mean age = 12 years, SD = 1·2) with complete unilateral cleft lip and palate (CUCLP) operated by a single surgeon with a one-stage method were evaluated. The management of the cleft lip and soft palate was comparable in all subjects; for hard palate repair, three different methods were used: bilateral von Langenbeck closure (b-vL group, n = 39), unilateral von Langenbeck closure (u-vL group, n = 56) and vomerplasty (v-p group, n = 42). Speech was assessed: (i) perceptually for the presence of a) hypernasality, b) compensatory articulations (CAs), c) audible nasal air emissions (ANE) and d) speech intelligibility; (ii) for the presence of compensatory facial grimacing, (iii) with clinical intra-oral evaluation and (iv) with videonasendoscopy. A total rate of hypernasality requiring pharyngoplasty was 5·1%; total incidence post-oral compensatory articulations (CAs) was 2·2%. The overall speech intelligibility was good in 84·7% of cases. Oronasal fistulas (ONFs) occurred in 15·7% b-vL subjects, 7·1% u-vL subjects and 50% v-p subjects (P < 0·001). No statistically significant intergroup differences for hypernasality, CAs and intelligibility were found (P > 0·1). In conclusion, the speech after early one-stage repair of CUCLP was satisfactory. The method of hard palate repair affected the incidence of ONFs, which, however, caused relatively mild and inconsistent speech errors.

Diagnosis and management of developmental dysplasia of the hip from triradiate closure through young adulthood

Abstract The current treatment of painful hip dysplasia in the mature skeleton is based on acetabular reorientation. Reorientation procedures attempt to optimize the anatomic position of the hyaline cartilage of the femoral head and acetabulum in regard to mechanical loading. Because the Bernese periacetabular osteotomy is a versatile technique for acetabular reorientation, it is helpful to understand the approach and be familiar with the criteria for an optimal surgical correction. The femoral side bears stigmata of hip dysplasia that may require surgical correction. Improvement of the head-neck offset to avoid femoroacetabular impingement has become routine in many hips treated with periacetabular osteotomy. In addition, intertrochanteric osteotomies can help improve joint congruency and normalize the femoral neck orientation. Other new surgical techniques allow trimming or reducing a severely deformed head, performing a relative neck lengthening, and trimming or distalizing the greater trochanter.  An increasing number of studies have reported good long-term results after acetabular reorientation procedures, with expected joint preservation rates ranging from 80% to 90% at the 10-year follow-up and 60% to 70% at the 20-year follow-up. An ideal candidate is younger than 30 years, with no preoperative signs of osteoarthritis. Predicted joint preservation in these patients is approximately 90% at the 20-year follow-up. Recent evidence indicates that additional correction of an aspheric head may further improve results.

Pre- and postnatal imaging of Pai syndrome with spontaneous intrauterine closure of a frontal cephalocele.

Pai syndrome is a rare congenital disorder characterized by cutaneous polyps of the face, pericallosal lipoma and median cleft lip. We report on a newborn girl with a variant of Pai syndrome presenting with all typical findings except a median cleft. In addition, fetal sonography and MRI showed the unique intrauterine evolution of a cephalocele into an atretic cephalocele.

Accelerated wound closure in vitro by fibroblasts from a subgroup of cleft lip/palate patients: role of transforming growth factor-α.

In a fraction of patients surgically treated for cleft lip/palate, excessive scarring disturbs maxillary growth and dento-alveolar development. Since certain genes are involved in craniofacial morphogenesis as well as tissue repair, a primary defect causing cleft lip/palate could lead to altered wound healing. We performed in vitro wound healing assays with primary lip fibroblasts from 16 cleft lip/palate patients. Nine foreskin fibroblast strains were included for comparison. Cells were grown to confluency and scratch wounds were applied; wound closure was monitored morphometrically over time. Wound closure rate showed highly significant differences between fibroblast strains. Statistically, fibroblast strains from the 25 individuals could be divided into three migratory groups, namely "fast", "intermediate", and "slow". Most cleft lip/palate fibroblasts were distributed between the "fast" (5 strains) and the "intermediate" group (10 strains). These phenotypes were stable over different cell passages from the same individual. Expression of genes involved in cleft lip/palate and wound repair was determined by quantitative PCR. Transforming growth factor-α mRNA was significantly up-regulated in the "fast" group. 5 ng/ml transforming growth factor-α added to the culture medium increased the wound closure rate of cleft lip/palate strains from the "intermediate" migratory group to the level of the "fast", but had no effect on the latter group. Conversely, antibody to transforming growth factor-α or a specific inhibitor of its receptor most effectively reduced the wound closure rate of "fast" cleft lip/palate strains. Thus, fibroblasts from a distinct subgroup of cleft lip/palate patients exhibit an increased migration rate into wounds in vitro, which is linked to higher transforming growth factor-α expression and attenuated by interfering with its signaling.

Patent foramen ovale and closure technique with the amplatzer occluder.

Proof that percutaneous closure of the patent foramen ovale (PFO) is superior to medical treatment is still incomplete. Paradoxical embolism is a rare event occurring over decades rather than years. None of the 4 randomized trials published carried enough patients or was followed up for long enough to reach superiority endpoints. All data, however, point to a benefit of PFO closure. Free wall erosion (exceedingly rare) and triggering of atrial fibrillation (in about 1% of patients) are the only noteworthy complications. They are outweighed by the supposedly prevented events of paradoxical embolisms, such as stroke, transient ischemic attacks, myocardial infarctions, or other systemic embolisms. Medical treatment with perhaps the exception of lifelong oral anticoagulation provides less protection. During a 10-year follow-up of a comparative study the annual mortality was significantly lower in the patients with PFO closure (0.4%) than in those with medical treatment (1.1%, P < 0.03). PFO closure can be accomplished in less than 1 hour with immediate resumption of physical activity. It represents thus a kind of mechanical vaccination.

Closure of patent foramen ovale for secondary prevention of cerebrovascular events

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people a patent foramen ovale (PFO) is increasingly searched for. In stroke of the elderly atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO related stroke over time is controversial and so is its prevention by PFO closure. Percutaneous PFO closure is a minimally invasive procedure which can be performed with high success and low morbidity. We review the rationale for PFO closure for secondary prevention of embolic events.