Le point sur l'ergométrie en 2012 dans le diagnostic de la maladie coronarienne.

Background In patients presenting with acute cardiac symptoms, abnormal ECG and raised troponin, myocarditis may be suspected after normal angiography. Aims To analyse cardiac magnetic resonance (CMR) findings in patients with a provisional diagnosis of acute coronary syndrome (ACS) in whom acute myocarditis was subsequently considered more likely. Methods and results 79 patients referred for CMR following an admission with presumed ACS and raised serum troponin in whom no culprit lesion was detected were studied. 13% had unrecognised myocardial infarction and 6% takotsubo cardiomyopathy. The remainder (81%) were diagnosed with myocarditis. Mean age was 45615 years and 70% were male. Left ventricular ejection fraction (EF) was 58610%; myocardial oedema was detected in 58%. A myocarditic pattern of late gadolinium enhancement (LGE) was detected in 92%. Abnormalities were detected more frequently in scans performed within 2 weeks of symptom onset: oedema in 81% vs 11% (p<0.0005), and LGE in 100% vs 76% (p<0.005). In 20 patients with both an acute (<2 weeks) and convalescent scan (>3 weeks), oedema decreased from 84% to 39% (p<0.01) and LGE from 5.6 to 3.0 segments (p¼0.005). Three patients presented with sustained ventricular tachycardia, another died suddenly 4 days after admission and one resuscitated 7 weeks following presentation. All 5 patients had preserved EF. Conclusions Our study emphasises the importance of access to CMR for heart attack centres. If myocarditis is suspected, CMR scanning should be performed within 14 days. Myocarditis should not be regarded as benign, even when EF is preserved.

Evaluation des pratiques d'irrigation, de fertilisation et d'application de pesticides dans l'agriculture périurbaine de Dakar, Sénégal

RESUMEL'agriculture urbaine et périurbalne - nommée ci-après AU - est un thème fort de recherche transversale, au vu des nombreux enjeux économiques, sociaux et environnementaux. L'objectif de cette recherche était de contribuer à une meilleure connaissance des processus de transfert de polluants et du cycle des nutriments à l'échelle locale, afin de déterminer sous quelles conditions l'AU de Dakar peut être pratiquée sans porter atteinte à la santé et à l'environnement.Une approche basée sur l'étude des processus géochimiques dans ie sol jusqu'à la nappe a été choisie, à l'échelle de la parcelle cultivée et à une échelle un peu plus large de la zone périurbaine de Dakar pour déterminer les influences du type d'occupation du sol.L'évaluation des impacts de l'irrigation avec des eaux usées brutes et des eaux de nappe saumâtres sur la qualité des sols (chapitre 2) a montré que l'alcalinité et les teneurs en calcium élevées des eaux saumâtres induisent la précipitation de CaC03 dans l'horizon superficiel du sol. Na remplace consécutivement Ca sur le complexe argilo-humique du sol et les bicarbonates diminuent dans la solution du sol. Le carbone organique dissout (COD) augmente significativement dans la solution du sol et dans la nappe sous-jacente. Malgré l'alcalinité et les teneurs très élevées en calcium des eaux usées, il y a peu de précipitation de CaC03 dans l'horizon superficiel du sol et une faible augmentation du sodium échangeable ESP. La nitrification de l'ammonium des eaux usées (moy 190mg/L à Pikine) produit des protons, qui ne sont plus tamponnés par les bicarbonates exportés hors du profil. Il y a alors une nette baisse de pH des sols irrigués par des eaux usées non traitées. Les sols irrigués par des eaux usées et saumâtres stockent moins de C et Ν que les sols de référence.L'évaluation de l'influence de l'occupation des sols en zone périurbaine sur à la nappe phréatique peu profonde (chapitre 3) a permis de déterminer les traceurs représentatifs de l'occupation du sol, à savoir Br/CI, NO3/CI et δ180-Ν03 pour l'irrigation par des eaux usées, pH et δ15Ν-Ν03 pour l'irrigation par des eaux de nappe, et Rb+Cr et Κ pour les lixiviats de fosses septiques. Ce chapitre a mis en évidence des points importants de la dynamique de l'azote en zone périurbaine sous deux occupations du sol : (1) la dénitrification est un processus important dans l'agrosystème périurbain de Dakar en bas de dune, dans les gleysols où l'on trouve des conditions temporairement réduites et un substrat organique favorables aux microorganismes de la dénitrification. Les teneurs en nitrates sont presque nulles avec irrigation d'eau de nappe. (2) en bas de pente, mais avec irrigation quotidienne par les eaux usées, l'apport continu d'ammonium inhibe probablement la dénitrification, mais favorise la volatilisation. (3) la nitrification de l'ammonium dans la nappe lors de la lixiviation des fosses septiques se distingue de la nitrification de l'ammonium dans la zone non saturée dans la zone d'agriculture périurbaine par la composition isotopique de l'oxygène de l'eau. Une comparaison des flux d'azote entre l'agrosystème et les quartiers périurbains de Dakar (chapitre 4) ont révélé que ces derniers étaient du même ordre de grandeur par unité de surface, à savoir 2-4 tonnes Ν /ha/an.L'évaluation des flux de pesticides dans l'agrosystème et des risques induits pour les eaux souterraines (chapitre 5) a révélé un fiux total de pesticides de 60kg/ha/an, totalisant 15 matières actives. Seules deux de ces matières actives sont autorisées par le comité des pesticides sahélien. Les pesticides les plus utilisés par les producteurs sont l'organochloré dicofol, les organophosphorés methamidophos, dimethoate et fenithrotion ainsi que le cabamate methomyl. Les flux les plus importants sont de 9 à 7 kg/ha/an (methomyl, methamidophos, ethoprophos et dicofol). Les pesticides qui présentent un risque élevé de contamination des eaux souterraines et qui devraient être prioritaires pour un suivi analytique sont : le carbofuran, le dimethoate, l'ethoprophos et le methomyl.En conclusion, une meilleure gestion de la fertilisation est nécessaire dans la zone d'AU de Dakar, afin de (1) réduire les pertes gazeuses qui contribuent à l'effet de serre, (2) de ralentir la minéralisation du carbone et de l'azote organiques pour créer un stock de C et Ν dans ces sols, (3) de limiter le lessivage dans la nappe et enfin, 4) d'augmenter l'efficacité d'utilisation de Ν par les plantes. Une optimisation de l'irrigation devrait limiter l'alcalinisation secondaire. Enfin, la mise en place d'une lutte intégrée ou biologique contre les ravageurs est indispensable afin de minimiser les risques pour les eaux souterraines et les mares permanentes.ABSTRACTUrban and periurban agriculture (UA) is an important issue in southern countries, because of its key role in their social and economical development and its environmental concern. The goal of this study was to contribute to a better understanding of pollutant transfer and nutrient cycling at the local scale, in order to implement the necessary improvements to guarantee the sustainability of this practice.An approach based on geochemical processes occurring in the vadose zone from the surface down to the groundwater level was chosen, at the scale of cultivated plots and at the regional scale of Dakar periurban areas, to determine the influence of land use.The assessment of irrigation with untreated domestic wastewater and brackish water on soil quality (chapter 2) showed: (1) that the high alkalinity and calcium contents of brackish water induce CaC03 precipitation in the top layer of the soil and therefore a replacement of Ca by Na on the clay- humic complexes, strongly marked during the dry season. Dissolved organic carbon (DOC) increased significantly in the soil solution and in the underlying groundwater. (2) in spite of the similarly high alkalinity and Ca contents of waste water, there is only little CaC03 precipitation and a low increase of the percentage of exchangeable sodium (ESP) in the soil top layer. The nitrification of the ammonium of wastewater (mean 190 mg/L in Pikine) produces protons, which are not any more buffered by bicarbonates exported out of the soil profile, which leads to a net decline of soil pH. Both soils irrigated with untreated wastewater and brackish water store less of C and Ν than soils irrigated with non saline groundwater.The assessment of the impact of land use on the shallow groundwater (chapter 3) allowed determining representative tracers of the land use. Low Br/CI ratio, high NO3/CI ratio and low δ1βΟ- nitrate indicated the influence of wastewater; high pH and high 515N-nitrates indicated the influence of brackish water together with high amendments of organic fertilizers; high Rb+Cr and Κ indicated the influence of poor sanitation facilities in periurban districts (septic tank leakage). This chapter also pointed out the following facts about the nitrogen dynamics : (1) denitrification is a key-process in the Dakar UA agrosystem in the gleysols irrigated with groundwater. The underlying groundwater is almost nitrate free. (2) in the Gleysols irrigated with waste water, ammonium inhibits denitrification but facilitate ammoniac volatilization. A comparison of nitrogen balance between the UA agrosystem and the periurban districts of Dakar (chapter 4) revealed similar flows per surface unit, namely 2-4 tons Ν / ha / year.The evaluation of pesticides use in the UA agrosystem and the risk assessment for the groundwater (chapter 5) revealed a total flow of pesticides of 60kg / ha / year, totalizing 15 active substances. Only two of these are authorized by the Sahelian Pesticides Committee. The most used pesticides are dicofol (organochlorinated), methamidophos, dimethoate and fenithrotion (organophosphate) as well as methomyl. (carbamate). The most important flows vary between 9 to 7 kg / ha / year. Pesticides with a high risk of groundwater contamination - according to SIRIS and EPRIP 2 indicators - are: carbofuran, dimethoate, ethoprophos and methomyl. These substances should be established as a priority for an analytical follow-up in the different environmental compartments.In conclusion, a better management of the fertilization is necessary in the Dakar UA, (1) to reduce the gaseous losses which contribute to greenhouse emissions (2) to slow down the mineralization of the organic carbon and the nitrogen, in order to enhance the C and Ν stock in these soils, (3) to limit the nitrate leaching in the groundwater and finally, 4) to increase the N-use efficiency of plants. An optimization of the irrigation scheme should limit the secondary sodisation if coupled with an increase the stable organic matter of the soil. An integrated or biologic crop pest strategy is urgently needed to minimize risks with respect to ground and surface water (ponds used for fishing).RESUME LARGE PUBLICL'agriculture mondiale connaît actuellement une crise majeure, affectée par les changements climatiques, la sécurité alimentaire et les dégradations de l'environnement. Elle n'a plus le rôle unique de produire, mais devient un élément essentiel de la protection des ressources naturelles et du paysage. Les politiques agricoles basées sur les marchés mondiaux devront se réorienter vers une agriculture locale basée sur le développement durable.La production alimentaire située dans l'enceinte des villes, nommée agriculture urbaine ou périurbaine (AU ci-après) joue un rôle important dans le contexte actuel d'accroissement de la population et de la pauvreté urbaines. L'AU concerne en effet la majorité des mégapoies du monde, fait vivre plus de 200 millions de personnes dans les pays du Sud, fournit jusqu'à 80% de la demande urbaine en certains produits frais, fait barrière à l'extension urbaine et permet un recyclage de certains déchets urbains. L'AU a pour particularité d'être à cheval entre des politiques rurales et urbaines, d'où un délaissement ce cette activité au secteur informel. Ce qui a développé de nombreuses stratégies à risques, comme à Dakar, où les petits producteurs périurbains irriguent quotidiennement avec des eaux usées domestiques par manque d'accès à une eau de bonne qualité et pour raccourcir les cycles de production. L'extrême précarité foncière des acteurs de l'AU de Dakar les empêchent d'investir à long terme et induit des pratiques inadéquates d'irrigation, d'usage de pesticides et de fertilisation de ces sols sableux.L'objectif de cette recherche était de contribuer à une meilleure connaissance des processus de transfert de polluants et du cycle des nutriments à l'échelle des parcelles cultivées par des eaux usées et des eaux saumâtres, afin de déterminer sous quelles conditions l'AU de Dakar peut être pratiquée et surtout maintenue sans porter atteinte à la santé et à l'environnement. Pour cela, une approche basée sur l'étude des processus géochimiques dans le sol jusqu'à la nappe a été choisie, à l'échelle de la parcelle cultivée et à une échelle un peu plus large de la zone périurbaine de Dakar pour déterminer les influences du type d'occupation du sol.Les résultats principaux de cette étude ont montré que (1) il y a un processus de salinisation anthropique des sols (sodisation) lors d'irrigation avec des eaux de nappe saumâtres, un processus accentué en saison sèche et lors d'années à pluviométrie déficitaire. Bien que les eaux usées soient aussi salines que les eaux de nappe, la salinisation des sols irrigués' par des eaux usées est limitée par l'ammonium présent dans les eaux usées (moy 190mg NH4/L à Pikine) qui produit de l'acidité lors de la transformation en nitrates dans le sol (nitrification). (2) les sols irrigués par des eaux usées (EU) stockent moins de C et Ν que les sois de référence, ce qui montrent bien que l'azote des eaux usées n'est pas disponible pour les plantes, mais est lessivé dans la nappe (100 à 450 mg/L N03 sous irrigation par EU, alors que la limite de OMS est de 50mg/L). (3) l'utilisation des isotopes stables des nitrates et des éléments traces, notamment le bore et le brome, ont permis de distinguer l'influence de l'irrigation par des eaux usées, de l'irrigation par des eaux de nappe et des lixiviats de fosses septiques sur les propriétés de la nappe. (4) Le processus de la dénitrification (atténuation naturelle des concentrations en nitrates de la nappe par biotransformation en azote gazeux) est important dans les zones basses de l'agrosystème périurbain de Dakar, sous irrigation par eaux naturelles (ΝΟ3 < 50mg/L). Tandis que sous habitat sans assainissement adéquat, les nitrates atteignent 300 à 700 mg/L. (5) Le flux total de pesticides dans l'AU est énorme (60kg/ha/an) totalisant 15 pesticides, dont deux seulement sont autorisés. Les pesticides les plus utilisés sont des insecticides organophosphorés et organochlorés classés extrêmement dangereux à dangereux par l'OMS, appliqués à des doses de 2 à 9 kg/ha/an. Les pesticides qui ont montré un risque élevé de contamination des eaux souterraines avec les indicateurs SIRIS et EPRIP2 sont : le carbofuran, le dimethoate, l'ethoprophos et le methomyl.En conclusion, nous recommandons la reconstitution d'un horizon superficiel des sols riche en matière organique stable et structuré par production locale de compost. Cette mesure réduira les pertes gazeuses contribuant à l'effet de serre, augmentera le stock de Ν dans ces sols, alors utilisable par les plantes et permettra de diminuer l'irrigation car la capacité de rétention de l'eau dans le sol sera accru, ce qui limitera le lessivage des nitrates dans la nappe et l'alcalinisation secondaire. Enfin, la mise en place d'une lutte intégrée ou biologique contre les ravageurs est indispensable afin de minimiser les risques pour les eaux souterraines et lesmares permanentes.

Amyloid arthropathy in patients undergoing periodical haemodialysis for chronic renal failure: a new complication.

Seven patients (five male and two female) with chronic renal failure (CRF) treated by periodical haemodialysis presented with swelling and effusion of more than three months' duration in knees (four bilateral), shoulders (two, one of them bilateral), elbow (one), and ankle (one). Four had a carpal tunnel syndrome both clinically and electromyographically (three bilateral). All patients had hyperparathyroidism secondary to their CRF, which was not due to amyloidosis in any of them. The dialysis duration period varied from five to 14 years, with an average of 8.6 years. Amyloid deposits (Congo red positive areas with green birefringence under polarising microscopy) were shown in six of the seven synovial biopsy specimens of the knee, in five of the sediments of the synovial fluids, and in specimens removed during carpal tunnel syndrome surgery. No amyloid was found in the biopsy specimen of abdominal fat of six of the patients. The finding of amyloid only in the synovial membrane and fluid, and carpal tunnel, its absence in abdominal fat, and the lack of other manifestations of generalised amyloidosis (cardiomyopathy, malabsorption syndrome, macroglossia, etc.) and of Bence Jones myeloma (protein immunoelectrophoresis normal) raises the possibility that this is a form of amyloidosis which is peculiar to CRF treated by periodical haemodialysis.

Isolated limb perfusion: distinct tourniquet and tumor necrosis factor effects on the early hemodynamic response.

HYPOTHESIS: Recent evidence indicates that tumor response rates after isolated limb perfusion (ILP) are improved when tumor necrosis factor (TNF) is added to the locoregional perfusion of high doses of chemotherapy. Other factors, related to the patient or the ILP procedure, may interfere with the specific role of TNF in the early hemodynamic response after ILP with TNF and high-dose chemotherapy. DESIGN: Case-control study. SETTING: Tertiary care university hospital. PATIENTS: Thirty-eight patients with a locoregionally advanced tumor of a limb treated by ILP with TNF and high-dose chemotherapy (TNF group) were compared with 31 similar patients treated by ILP with high-dose chemotherapy alone (non-TNF group). INTERVENTIONS: Swan-Ganz catheter hemodynamic recordings, patients' treatment data collection, and TNF and interleukin 6 plasma level measurements at regular intervals during the first 36 hours following ILP. MAIN OUTCOME MEASURES: Hemodynamic profile and total fluid and catecholamine administration. RESULTS: In the TNF group, significant changes were observed (P<.006): the mean arterial pressure and the systemic vascular resistance index decreased, and the temperature, heart rate, and cardiac index increased. These hemodynamic alterations started when the ILP tourniquet was released (ie, when or shortly after the systemic TNF levels were the highest). The minimal mean arterial pressure, the minimal systemic vascular resistance index, the maximal cardiac index, the intensive care unit stay, and the interleukin 6 maximal systemic levels were significantly (P<.001 for all) correlated to the log(10) of the systemic TNF level. In the non-TNF group, only a brief decrease in the blood pressure following tourniquet release and an increase in the temperature and in the heart rate were statistically significant (P<.006). Despite significantly more fluid and catecholamine administration in the TNF group, the mean arterial pressure and the systemic vascular resistance index were significantly (P<.001) lower than in the non-TNF group. CONCLUSIONS: Release of the tourniquet induces a blood pressure decrease that lasts less than 1 hour in the absence of TNF and that is distinct from the septic shock-like hemodynamic profile following TNF administration. The systemic TNF levels are correlated to this hemodynamic response, which can be observed even at low TNF levels.

Copeptin as a diagnostic biomarker for sepsis-related deaths.

Copeptin has been shown to increase in patients with sepsis, severe sepsis and septic shock. In the study herein described, copeptin was measured in a series of sepsis-related fatalities and control cases that underwent medico-legal investigations. No age-dependent differences in copeptin levels in either sepsis or control cases were observed. No correlation between copeptin concentrations and postmortem interval was identified in either group. Copeptin levels were significantly higher in sepsis cases. Moreover, copeptin concentrations in septic cases correlated with procalcitonin, C-reactive protein and interleukin 6 values. These preliminary findings seem to indicate that copeptin can be reliably measured in biological samples collected during postmortem investigations. These results also suggest that hemodynamic instability associated with sepsis and septic shock can be characterized by copeptin measurement also in the forensic casework.

Infection after total ankle replacement : A 5-year retrospective analysis of 92 implanted ankle prostheses (2004-2008).

Objectives: Total ankle replacement (TAR) is increasingly used for treatment of primary or posttraumatic arthritis of the ankle joint, if joint movement is intended to be preserved. Data on characteristics and treatment of ankle prosthetic joint infection (PJI) is limited and no validated therapeutic algorithm exist. Therefore, we analyzed all infections, which occurred in a cohort of implanted ankle prostheses during a 5-year-period.Methods: Between 06/2004 and 12/2008, all patients with an implanted ankle prosthesis at our institution were retrospectively reviewed. All patients were operated by the same surgical team. Ankle PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract, or microbial growth in periprosthetic tissue or sonication fluid of the removed prosthesis. The surgery on the infected ankle prosthesis and the follow-up were performed by the surgical team, who implanted the prosthesis. A specialized septic team consisting of an orthopaedic surgeon and infectious diseases consultant were included in the treatment.Results: During the study period, 92 total ankle prostheses were implanted in 90 patients (mean age 61 years, range 28-80 years). 78 patients had posttraumatic arthritis, 11 rheumatoid arthritis and 3 other degenerative disorder. Ankle PJI occurred in 3 of 92 TAR (3.3%), occurring 1, 2 and 24 months after implantation; the causative organisms were Enterobacter cloacae, Streptococcus pyogenes and Staphylococcus epidermidis, respectively. The ankle prosthesis was removed in all infected patients, including debridement of the surrounding tissue was debrided and insertion of an antibiotic loaded spacer. Provisional arthrodesis was performed by external fixation in two patients and by plaster cast in one. A definitive ankle arthrodesis with a retrograde nail was performed 6 to 8 weeks after prosthesis removal. One patient needed a flap coverage. All 3 patients received intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 4-6 weeks. At follow-up visit up to 18 months after start of treatment, all patients were without clinical or laboratory signs of infection.Conclusions: The infection incidence after TAR was 3.3%, which is slightly higher than reported after hip (<1%) or knee arthroplasty (<2%). A two-step approach consisting of removal of the infected prosthesis, combined with local and systemic antibiotic treatment, followed by definitive ankle arthrodesis shows good results. Larger patient cohort and longer follow-up evaluation is needed to define the optimal treatment approach for ankle PJI.

Carnitine deficiency in chronic critical illness.

PURPOSE OF REVIEW: New insight in mitochondrial physiology has highlighted the importance of mitochondrial dysfunction in the metabolic and neuroendocrine changes observed in patients presenting with chronic critical illness. This review highlights specifically the importance of carnitine status in this particular patient population and its impact on beta-oxidation and mitochondrial function. RECENT FINDINGS: The main function of carnitine is long chain fatty acid esterification and transport through the mitochondrial membrane. Carnitine depletion should be suspected in critically ill patients with risk factors such as prolonged continuous renal replacement therapy or chronic parenteral nutrition, and evidence of beta-oxidation impairments such as inappropriate hypertriglyceridemia or hyperlactatemia. When fatty acid oxidation is impaired, acyl-CoAs accumulate and deplete the CoA intramitochondrial pool, hence causing a generalized mitochondrial dysfunction and multiorgan failure, with clinical consequences such as muscle weakness, rhabdomyolysis, cardiomyopathy, arrhythmia or sudden death. In such situations, carnitine plasma levels should be measured along with a complete assessment of plasma amino acid, plasma acylcarnitines and urinary organic acid analysis. Supplementation should be initiated if below normal levels (20 μmol/l) of carnitine are observed. In the absence of current guidelines, we recommend an initial supplementation of 0.5-1 g/day. SUMMARY: Metabolic modifications associated with chronic critical illness are just being explored. Carnitine deficiency in critically ill patients is one aspect of these profound and complex changes associated with prolonged stay in ICU. It is readily measurable in the plasma and can easily be substituted if needed, although guidelines are currently missing.

PPARβ/δ activation blocks lipid-induced inflammatory pathways in mouse heart and human cardiac cells.

Owing to its high fat content, the classical Western diet has a range of adverse effects on the heart, including enhanced inflammation, hypertrophy, and contractile dysfunction. Proinflammatory factors secreted by cardiac cells, which are under the transcriptional control of nuclear factor-κB (NF-κB), may contribute to heart failure and dilated cardiomyopathy. The underlying mechanisms are complex, since they are linked to systemic metabolic abnormalities and changes in cardiomyocyte phenotype. Peroxisome proliferator-activated receptors (PPARs) are transcription factors that regulate metabolism and are capable of limiting myocardial inflammation and hypertrophy via inhibition of NF-κB. Since PPARβ/δ is the most prevalent PPAR isoform in the heart, we analyzed the effects of the PPARβ/δ agonist GW501516 on inflammatory parameters. A high-fat diet induced the expression of tumor necrosis factor-α, monocyte chemoattractant protein-1, and interleukin-6, and enhanced the activity of NF-κB in the heart of mice. GW501516 abrogated this enhanced proinflammatory profile. Similar results were obtained when human cardiac AC16 cells exposed to palmitate were coincubated with GW501516. PPARβ/δ activation by GW501516 enhanced the physical interaction between PPARβ/δ and p65, which suggests that this mechanism may also interfere NF-κB transactivation capacity in the heart. GW501516-induced PPARβ/δ activation can attenuate the inflammatory response induced in human cardiac AC16 cells exposed to the saturated fatty acid palmitate and in mice fed a high-fat diet. This is relevant, especially taking into account that PPARβ/δ has been postulated as a potential target in the treatment of obesity and the insulin resistance state.

Endocan measurement for the postmortem diagnosis of sepsis

The vascular endothelium has been shown to play a pivotal role in the pathophysiology of sepsis through the expression of surface proteins and secretion of soluble mediators. Endocan (endothelial cell-specific molecule-1), a 50-kDa dermatan sulfate proteoglycan, is expressed by endothelial cells in lung and kidney and can be detected at low levels in the serum of healthy subjects. Increased concentrations were described in patients with sepsis, severe sepsis and septic shock compared to healthy individuals, with serum concentrations related to the severity of illness. In the present study, we investigated endocan, procalcitonin and C-reactive protein in postmortem serum from femoral blood in a series of sepsis-related fatalities and control individuals who underwent medicolegal investigations. Endocan was also measured in pericardial fluid. Two study groups were prospectively formed, a sepsis-related fatalities group and a control group. The sepsis-related fatalities group consisted of sixteen forensic autopsy cases with documented clinical diagnosis of sepsis in vivo. The control group consisted of sixteen forensic autopsy cases with various noninfectious causes of death. Postmortem serum endocan concentrations were significantly higher in the sepsis group, with values ranging from 0.519ng/ml to 6.756ng/ml. In the control group, endocan levels were undetectable in eleven out of sixteen cases. The results of the data analysis revealed similar endocan concentrations in the pericardial fluid of both studied groups. Endocan can be considered a suitable biological parameter for the detection of sepsis-related deaths in forensic pathology routine.

Neurodevelopmental outcome of neonates treated with nitric oxide for persistent pulmonary hypertension

Persistent pulmonary hypertension of the newborn (PPHN) is a life threatening condition associated with an increased risk of neurodevelopmental impairment. The recommended treatment for this condition is inhaled nitric oxide (iNO) and has been used in our Neonatal Intensive Care Unit since 1998. We prospectively offered neurodevelopmental follow-up to children treated with iNO for PPHN, including extensive neurological evaluation, developmental/cognitive evaluation at 18 months and 3.5-5 years old, and evaluated the rate of severe and moderate handicap and normal neurodevelopmental outcome, compared to a control group and the literature. Population consisted of 29 patients treated only with iNO, born between 01.01.1999 and 31.12.2005 (study group), and 32 healthy term infants born in 1998 in our maternity (control group). During those seven years, 65 infants were admitted in our Unit with PPHN, of whom 40 were treated with iNO alone. 34 children survived (85%) and were offered neurodevelopmental follow-up, 7 children were lost to follow-up due to various reasons. 22 children were examined at the age of 18 months (76%) with a rate of moderate handicap of 22% (2 with expressive language delay, 2 with difficult behavior, and 1 child with moderate hearing loss), and a rate of major handicap of 4.5% (1 child with cerebral palsy due to perinatal stroke, and moderate hearing loss). At preschool age, 17 (50%) were examined, the rate of moderate handicap was 22% (4 borderline intelligence, 1 hearing loss), and the rate of major handicap was 4.5% (one child with cerebral palsy and hearing loss), compared to 26.9% and 0% in the control group. Mean developmental quotient at 18 months was 100.3 ± 8.7 (control group 118.3), and at preschool age mean cognitive indices were within normal limits for the 2 tests performed at 3.5 or 5 years (108 ± 21, 94.4 ± 17). Most of the children with a less favorable neurodevelopmental outcome suffered from birth asphyxia (ruptured uterus, placental abruption, maternal hypotension, diabetic cardiomyopathy), and notably, the 2 children with sensorineural hearing loss both suffered from severe hypoxic-ischemic enkelopathy. Treatment with iNO was not the direct cause of the neurodevelopmental impairments observed in children treated for PPHN.

Perforation colique néonatale focale spontanée en dehors de la grande prématurité : rare et potentiellement insidieuse [Focal spontaneous colic perforation in term or near-term neonates: rare and potentially insidious].

Two cases of neonatal focal spontaneous colic perforations are reported. The 1st infant, born at 36 3/7 weeks gestational age, presented on day 3 with crying, abdominal distension, and liquid stools. Clinical examination showed a slightly irritable hypothermic (35.7 °C) infant with a distended abdomen and few bowel sounds. Blood tests were normal apart from an elevated C-reactive protein level (59 mg/l). The abdomen x-ray was erroneously considered normal. The infant's condition remained stable for nearly 3 days. After reviewing the initial x-ray, pneumoperitoneum was suspected and confirmed by a cross-table lateral abdominal x-ray. The infant was started on antibiotics and operated. Macroscopically, the entire gut was normal apart from a focal sigmoid perforation, which was stitched. A transmural colic biopsy revealed focal vascular dilation but was negative for necrotising enterocolitis or Hirschsprung disease. The infant recovered quickly. She is now a healthy, normal 3-year-old. The 2nd infant, born at 38 5/7 weeks gestational age, presented between day 1 and 2 with clinical signs of infection associated with slowly progressive ileus. The chest and abdomen x-ray was mistakenly considered normal. Frank septicemia developed. After reviewing the initial x-ray, pneumoperitoneum was suspected and confirmed by a cross-table lateral abdominal x-ray. The infant was operated. Macroscopically, the small intestine was normal, the ascending and transverse colons were dilated, and the descending and sigmoid colons were narrow. Three cecal perforations were discovered and stitched. An ileostomy and multiple colic biopsies were also performed. The postoperative course was complicated by persistent septic ileus due to descending and sigmoid colon leaks, which led to colic resections with end-to-end anastomosis. Rectal aspiration biopsies were also performed. At 1 month of age, the infant was discharged from the hospital. The ileostomy was closed in two steps at 2 and 5 months of age. A normal sweat test excluded cystic fibrosis. All colic and rectal biopsies revealed nonspecific inflammatory signs and excluded necrotizing enterocolitis and Hirschsprung disease. Nonspecific irregular thinning of muscularis mucosae and muscularis propria were observed in the two resected colic segments. The boy is now a healthy 7-year-old. The incidence of neonatal focal spontaneous colic perforations at term or close to term is unknown but probably very rare. Our department is the neonatal referral center for approximately 14,000 annual births. In the last 10 years (2000-2009), out of 5115 neonatal admissions in our unit, only ten cases have presented a neonatal spontaneous intestinal perforation, seven of ten in very-low-birth-weight infants and three of ten in term or near-term neonates (one with Hirschsprung disease and the two cases reported herein). In the same period, 108 infants suffered from necrotizing enterocolitis, seven of 108 were term infants and 6 out of 7 had a congenital heart disease. The medical literature is poor on the subject of focal spontaneous colic perforations at term; no risk factor is described. The most specific clinical sign seems to be the abdominal distension. The presence of pneumoperitoneum on an abdominal x-ray is the most sensitive paraclinical sign. In case of an intestinal perforation, surgery must be performed quickly. The vital prognosis seems to be good. The objective of this study was to draw pediatricians' attention to focal spontaneous colic perforations in term or close to term newborns. In the cases reported, the diagnostic delays could have been prevented if the entity - with its radiological manifestation - had been well known.

Diagnostic contribution of cardiac magnetic resonance in patients with acute coronary syndrome and culprit-free angiograms.

BACKGROUND: In spite of robust knowledge about underlying ischemic myocardial damage, acute coronary syndromes (ACS) with culprit-free angiograms raise diagnostic concerns. The present study aimed to evaluate the additional value of cardiac magnetic resonance (CMR) over commonly available non-CMR standard tests, for the differentiation of myocardial injury in patients with ACS and non-obstructed coronary arteries. MATERIAL/METHODS: Patients with ACS, elevated hs-TnT, and a culprit-free angiogram were prospectively enrolled into the study between January 2009 and July 2013. After initial evaluation with standard tests (ECG, echocardiography, hs-TnT) and provisional exclusion of acute myocardial infarction (AMI) in coronary angiogram, patients were referred for CMR with the suspicion of myocarditis or Takotsubo cardiomyopathy (TTC). According to the result of CMR, patients were reclassified as having myocarditis, AMI, TTC, or non-injured myocardium as assessed by late gadolinium enhancement. RESULTS: Out of 5110 patients admitted with ACS, 75 had normal coronary angiograms and entered the study; 69 of them (92%) were suspected for myocarditis and 6 (8%) for TTC. After CMR, 49 patients were finally diagnosed with myocarditis (65%), 3 with TTC (4%), 7 with AMI (9%), and 16 (21%) with non-injured myocardium. The provisional diagnosis was changed or excluded in 23 patients (31%), with a 9% rate of unrecognized AMI. CONCLUSIONS: The study results suggest that the evaluation of patients with ACS and culprit-free angiogram should be complemented by a CMR examination, if available, because the initial work-up with non-CMR tests leads to a significant proportion of misdiagnosed AMI.

Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome.

BACKGROUND: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II. METHODS: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days. RESULTS: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 ± 16 years, SAPS II score 39 ± 16, SOFA score 7.6 ± 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for ≤ 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality. CONCLUSIONS: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.

Current features of infective endocarditis in elderly patients: results of the International Collaboration on Endocarditis Prospective Cohort Study.

BACKGROUND: Elderly patients are emerging as a population at high risk for infective endocarditis (IE). However, adequately sized prospective studies on the features of IE in elderly patients are lacking. METHODS: In this multinational, prospective, observational cohort study within the International Collaboration on Endocarditis, 2759 consecutive patients were enrolled from June 15, 2000, to December 1, 2005; 1056 patients with IE 65 years or older were compared with 1703 patients younger than 65 years. Risk factors, predisposing conditions, origin, clinical features, course, and outcome of IE were comprehensively analyzed. RESULTS: Elderly patients reported more frequently a hospitalization or an invasive procedure before IE onset. Diabetes mellitus and genitourinary and gastrointestinal cancer were the major predisposing conditions. Blood culture yield was higher among elderly patients with IE. The leading causative organism was Staphylococcus aureus, with a higher rate of methicillin resistance. Streptococcus bovis and enterococci were also significantly more prevalent. The clinical presentation of elderly patients with IE was remarkable for lower rates of embolism, immune-mediated phenomena, or septic complications. At both echocardiography and surgery, fewer vegetations and more abscesses were found, and the gain in the diagnostic yield of transesophageal echocardiography was significantly larger. Significantly fewer elderly patients underwent cardiac surgery (38.9% vs 53.5%; P < .001). Elderly patients with IE showed a higher rate of in-hospital death (24.9% vs 12.8%; P < .001), and age older than 65 years was an independent predictor of mortality. CONCLUSIONS: In this large prospective study, increasing age emerges as a major determinant of the clinical characteristics of IE. Lower rates of surgical treatment and high mortality are the most prominent features of elderly patients with IE. Efforts should be made to prevent health care-associated acquisition and improve outcomes in this major subgroup of patients with IE.