Reduced atrial emptying after orthotopic heart transplantation masquerading as restrictive transmitral Doppler flow pattern?

BACKGROUND: An elevated early (E) to late (A) diastolic filling velocities ratio, typically seen in advanced diastolic dysfunction, has also been observed after cardioversion of atrial fibrillation as a consequence of the depressed left atrial (LA) contractility. We hypothesized that the impaired LA contractile function demonstrated after orthotopic cardiac transplantation (OCT) could also lead to this "pseudorestrictive" pattern. METHOD: E/A ratio related to the tissue Doppler early mitral annular velocity (Ea) as preload-independent index of LV relaxation was evaluated in all consecutive OCT patients between 2005 and 2007. RESULTS: The study population comprised 48 patients 97 ± 77 months after OCT. Thirty-two patients (67%) had an E/A ratio > 2. LV systolic function and myocardial relaxation assessed by the Ea velocity were similar compared to patients with normal ratio (61 ± 6% vs. 60 ± 12%, P = 0.854 and 15 ± 4 cm/s vs. 14 ± 3 cm/s, r = 0.15, P = 0.323, respectively). On the other hand, the proportion of the recipient and donor LA cuffs as estimated by the recipient/global LA area ratio and the LA emptying fraction significantly correlated with the E/A ratio (r = 0.40, P = 0.005 and r =-0.33, P = 0.022, respectively). CONCLUSION: Our study shows that there is a high prevalence of elevated E/A ratio after standard OCT which seems mainly related to reduced LA contractility. Recognition of this "pseudorestrictive" pattern may avoid misdiagnosis of diastolic dysfunction.

Hospitalized women experiencing an episode of excessive oral anticoagulation had a higher bleeding risk than men.

OBJECTIVE: Overanticoagulated medical inpatients may be particularly prone to bleeding complications. Among medical inpatients with excessive oral anticoagulation (AC), we sought to identify patient and treatment factors associated with bleeding. METHODS: We prospectively identified consecutive patients receiving oral AC admitted to the medical ward of a university hospital (February-July 2006) who had at least one international normalized ratio (INR) value >3.0 during the hospital stay. We recorded patient characteristics, AC-related factors, and concomitant treatments (e.g., platelet inhibitors) that increase the bleeding risk. The outcome was overall bleeding, defined as the occurrence of major or minor bleeding during the hospital stay. We used logistic regression to explore patient and treatment factors associated with bleeding. RESULTS: Overall, 145 inpatients with excessive oral AC comprised our study sample. Atrial fibrillation (59%) and venous thromboembolism (28%) were the most common indications for AC. Twelve patients (8.3%) experienced a bleeding event. Of these, 8 had major bleeding. Women had a somewhat higher risk of major bleeding than men (12.5% vs 4.1%, p = 0.08). Multivariable analysis demonstrated that female gender was independently associated with bleeding (odds ratio [OR] 4.3, 95% confidence interval [95% C1] 1.1-17.8). Age, history of major bleeding, value of the index INR, and concomitant treatment with platelet inhibitors were not independent predictors of bleeding. CONCLUSIONS: We found that hospitalized women experiencing an episode of excessive oral AC have a 4-fold increased risk of bleeding compared with men. Whether overanticoagulated women require more aggressive measures of AC reversal must be examined in further studies.

Rituximab dans le traitement des maladies rénales glomérulaires: indications et evidences cliniques [Rationale and clinical evidence for the use of rituximab in glomerular diseases].

Autoimmune glomerulopathies are an important cause of chronic kidney disease. Conventional treatments based on steroids, antiproliferative and cytotoxic agents are efficacious, but highly toxic. Because of their central role in the pathogenesis of autoimmunity, B cells have become an attractive therapeutic target. Rituximab is a monoclonal antibody directed against CD20 expressed on the surface of B cells, inducing profound depletion of B cells in the peripheral blood. In spite of encouraging results regarding the off-label use of Rituximab in membranous nephropathy, systemic lupus erythematosus and small vessel vasculitis, controlled, long-term data, and data with specific renal endpoints are currently lacking.

Vaccinia immune globulin: current policies, preparedness, and product safety and efficacy.

In 1980 the World Health Organization declared that smallpox was eradicated from the world, and routine smallpox vaccination was discontinued. Nevertheless, samples of the smallpox virus (variola virus) were retained for research purposes, not least because of fears that terrorist groups or rogue states might also have kept samples in order to develop a bioweapon. Variola virus represents an effective bioweapon because it is associated with high morbidity and mortality and is highly contagious. Since September 11, 2001, countries around the world have begun to develop policies and preparedness programs to deal with a bioterror attack, including stockpiling of smallpox vaccine. Smallpox vaccine itself may be associated with a number of serious adverse events, which can often be managed with vaccinia immune globulin (VIG). VIG may also be needed as prophylaxis in patients for whom pre-exposure smallpox vaccine is contraindicated (such as those with eczema or pregnant women), although it is currently not licensed in these cases. Two intravenous formulations of VIG (VIGIV Cangene and VIGIV Dynport) have been licensed by the FDA for the management of patients with progressive vaccinia, eczema vaccinatum, severe generalized vaccinia, and extensive body surface involvement or periocular implantation following inadvertent inoculation.

When information can save lives: the duty to warn relatives about sudden cardiac death and environmental risks.

In certain cases of sudden death, forensic experts may discover during an investigation or autopsy that family members of the deceased are also at risk of harm-from genetic disease, for instance. But do they have a duty to warn them? Looking at similar duties of physicians and researchers to warn third parties of risk suggests they do.

International consensus guidelines on the management of cytomegalovirus in solid organ transplantation.

Cytomegalovirus (CMV) remains one of the most common infections after solid organ transplantation, resulting in significant morbidity, graft loss, and occasional mortality. Management of CMV varies considerably among transplant centers. A panel of experts on CMV and solid organ transplant was convened by The Infectious Diseases Section of The Transplantation Society to develop evidence and expert opinion-based consensus guidelines on CMV management including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues.

Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry.

BACKGROUND: Transcatheter aortic valve-in-valve implantation is an emerging therapeutic alternative for patients with a failed surgical bioprosthesis and may obviate the need for reoperation. We evaluated the clinical results of this technique using a large, worldwide registry. METHODS AND RESULTS: The Global Valve-in-Valve Registry included 202 patients with degenerated bioprosthetic valves (aged 77.7±10.4 years; 52.5% men) from 38 cardiac centers. Bioprosthesis mode of failure was stenosis (n=85; 42%), regurgitation (n=68; 34%), or combined stenosis and regurgitation (n=49; 24%). Implanted devices included CoreValve (n=124) and Edwards SAPIEN (n=78). Procedural success was achieved in 93.1% of cases. Adverse procedural outcomes included initial device malposition in 15.3% of cases and ostial coronary obstruction in 3.5%. After the procedure, valve maximum/mean gradients were 28.4±14.1/15.9±8.6 mm Hg, and 95% of patients had ≤+1 degree of aortic regurgitation. At 30-day follow-up, all-cause mortality was 8.4%, and 84.1% of patients were at New York Heart Association functional class I/II. One-year follow-up was obtained in 87 patients, with 85.8% survival of treated patients. CONCLUSIONS: The valve-in-valve procedure is clinically effective in the vast majority of patients with degenerated bioprosthetic valves. Safety and efficacy concerns include device malposition, ostial coronary obstruction, and high gradients after the procedure.

Repeated sprinting on natural grass impairs vertical stiffness but does not alter plantar loading in soccer players.

This study aimed to determine changes in spring-mass model (SMM) characteristics, plantar pressures, and muscle activity induced by the repetition of sprints in soccer-specific conditions; i.e., on natural grass with soccer shoes. Thirteen soccer players performed 6 × 20 m sprints interspersed with 20 s of passive recovery. Plantar pressure distribution was recorded via an insole pressure recorder device divided into nine areas for analysis. Stride temporal parameters allowed to estimate SMM characteristics. Surface electromyographic activity was monitored for vastus lateralis, rectus femoris, and biceps femoris muscles. Sprint time, contact time, and total stride duration lengthened from the first to the last repetition (+6.7, +12.9, and +9.3%; all P < 0.05), while flight time, swing time, and stride length remained constant. Stride frequency decrease across repetitions approached significance (-6.8%; P = 0.07). No main effect of the sprint number or any significant interaction between sprint number and foot region was found for maximal force, mean force, peak pressure and mean pressure (all P > 0.05). Center of mass vertical displacement increased (P < 0.01) with time, together with unchanged (both P > 0.05) peak vertical force and leg compression. Vertical stiffness decreased (-15.9%; P < 0.05) across trials, whereas leg stiffness changes were not significant (-5.9%; P > 0.05). Changes in root mean square activity of the three tested muscles over sprint repetitions were not significant. Although repeated sprinting on natural grass with players wearing soccer boots impairs their leg-spring behavior (vertical stiffness), there is no substantial concomitant alterations in muscle activation levels or plantar pressure patterns.

Place des antiarthrosiques symptomatiques d'action lente dans l'arthrose (sulfate de chondroïtine, glucosamine, acide hyaluronique) [Role of slow-acting anti-arthritic agents in osteoarthritis (chondroitin sulfate, glucosamine, hyaluronic acid)].

Osteoarthritis (OA) is one of the major causes of pain and of outpatient's clinics. 15 years ago, physiopathology of OA and its potential therapeutic targets were announced to be better understood, but the results of therapeutic trials were finally not as convincing as expected. Slow Acting Drugs (SADs) are part of the treatments evaluated in OA. Even if evidence based medicine is low, positive effects of SADs have been observed. We can reasonably propose these treatments for a short test period. It can sometimes enable us to decrease the dosage of others treatment such as NSAIDs. In any case, the physician must properly inform the patient about products available in Switzerland and must be aware of degrees of purity and costs of the products available on the intemet.

Ponction lombaire [Lumbar puncture]

La ponction lombaire (PL) est un geste fréquent en médecine interne, en particulier dans les services d'urgences. Dans cet article, nous présentons une description détaillée de ce geste en donnant quelques conseils pratiques pour sa réussite, la gestion des cas difficiles et la prévention des complications. Nous abordons aussi des questions pratiques comme l'indication à une imagerie cérébrale avant le geste et la mobilisation après la PL. La connaissance des indications, des détails de la procédure ainsi que des complications potentielles et de leur prise en charge constitue la base pour une information complète à donner au patient. Lumbar puncture (LP) is a procedure frequently performed by internists. The aim of this article is to describe in detail the procedure, to give some practical advices to always succeed in doing a lumbar puncture and to discuss the most frequent complications, how to prevent them and how to treat them. We will also answer some frequently asked questions, such as indications to perform neuroimaging before a lumbar puncture, or patient mobilisation after LP. Knowledge of these points is key to give a complete information to the patients and obtain an informed consent

Dietary fat, lipogenesis and energy balance.

Today, there are still uncertainties about the role of exogenous fat on body fat regulation. Early models of energy utilization (for example, Kleiber's, early 20th century) failed to take into account the nature of substrate oxidized in the control of food intake, whereas more recent models (e.g., Flatt's model, end of 20th century) did. Excess body fat storage is ultimately a problem of chronic positive energy balance mediated by a poor control of energy intake or/and a blunted total energy expenditure. Excess fat storage can stem from exogenous fat and to a more limited extent by nonfat substrates precursors transformed into body fat, mostly from carbohydrates, a process known as de novo lipogenesis. When considered over periods of weeks, months or years, total fat balance is closely related to energy balance. Over periods of days, the net change in fat balance is quantitatively limited as compared to the size of endogenous fat storage. The issues discussed in this article primarily include the stimulation of de novo lipogenesis after acute or prolonged CHO overfeeding and whether de novo lipogenesis is a risk factor for obesity development.

Spurious hyperphosphatemia in a patient with alteplase-locked central venous catheter.

Alteplase has been shown to be effective in preventing central venous access clotting in patients on hemodialysis. Because of a high phosphorus content in its excipient, it can inadvertently contaminate blood samples, leading the physician in care of the patient to erroneously increase dialysis time or change diet in order to control the pseudo-hyperphosphatemia.

Péritonite infectieuse en dialyse péritonéale: une complication trop redoutée [Infectious peritonitis in peritoneal dialysis: an over-emphasized complication].

Peritoneal dialysis is an extrarenal epuration modality which uses physiological properties of peritoneum as a dialysis membrane. Despite the improvement of peritoneal dialysis techniques in the last ten years, peritonitis remains one of the most redoubt complications. Peritonitis may sometimes lead to technical failures, which need catheter removing, but rarely lead to death. Our retrospective study at the dialysis center of CHUV has analyzed factors which can predict this kind of complication. It calculates peritonitis rate and median peritonitis free-survival for different groups of patients. It also describes causatives organisms and their sensitivity to antibiotics.