Sick sinus syndrome: strategies for reducing mortality.

The evolution of sick sinus syndrome is slow, and its clinical and electrocardiographic manifestations are intermittent. A-V and I-V conduction disturbances often arise, but incidence of defects with clinical consequences is too low. Death rate, when large groups are considered, is slightly higher than that of the general population of the same age and with similar pathologies. Mortality depends on concomitant pathologies, on the development of congestive heart failure, on the arterial thromboembolism and on the type of sinus disease. The use of ventricular pacemakers (VVI) did not reduce mortality. Atrial pacing (AAI) gives the auricles electrical stability preventing fibrillation and systemic embolism. The hemodynamic role of the auricles is also preserved. As a consequence, death rate is reduced when AAI is used. In cases with a-v conduction disturbances or with paroxysmal atrial fibrillation, dual chamber pacing (DDD) is preferable because it permits ventricular pacing to be continued even if a-v block or paroxysmal or chronic atrial fibrillation appears. When using ventricular pacing and in cases in which pacing is not considered, warfarin or aspirin can prevent strokes and systemic embolism. In bradycardia-tachycardia syndrome requiring treatment of arrhythmias dual chamber pacemaker must be implanted.     

Three-dimensional biomechanical properties of the human rectum evaluated with magnetic resonance imaging

A method to evaluate the three-dimensional (3-D) geometry of the human gastrointestinal wall may be valuable for understanding tissue biomechanics, mechano-sensation and function. In this paper we present a magnetic resonance imaging (MRI) based method to determine rectal geometry and validation of data obtained in three volunteers. A specially designed rectal bag was filled in a stepwise manner while MRI and bag pressure were recorded. 3-D models of curvatures, radii of curvature, tension and stress were generated and the circumferential and longitudinal strains were calculated. The computed bag volumes corresponded to the infused volumes. A pronounced bag elongation and decrease in wall thickness was observed during the bag filling. The spatial distributions of the biomechanical parameters were distinctly different between individuals and non-homogeneous throughout the rectal wall due to its complex geometry. The average tension and stress increased as a function of infused volume and circumferential strain. The present study provides a method for characterizing the complex in vivo 3-D geometry of the human rectum. The non-homogenous spatial curvature distribution suggests that simple estimates of tension based on pressure and volume do not reflect the true 3-D biomechanical properties of the rectum.     

A new diagnostic method of spondylodiscitis. Magnetic resonance imaging

Twenty four patients who were hospitalized for a suspicion of spondylodiscitis were prospectively evaluated with magnetic resonance imaging (MRI), radiology and radionuclide studies. Fifteen patients had an infectious spondylodiscitis, four had a vertebral degenerative disease, four had a rheumaticus spondylodiscitis, one had a chemical spondylodiscitis. The microbiological examinations and the clinical development bore the diagnosis out. Seven patients underwent Indium 111 scanning. The results of this scanning were correlated with MRI results. The MRI was performed with a 0.35 T whole body superconducting unit using spin echo technique. All patients were studied in the sagittal plane with two pulse sequences and more often with a surface-coil: TR 500 msec./TE 28 msec. and TR 2,000 msec./TE 60 msec. In all cases of true infectious spondylodiscitis the MRI results finding were characteristics. On the image obtained with the TR 500 msec./TE 28 msec., there was a confluent decreased signal intensity from the vertebral bodies and the intervertebral disk space. On the image obtained with TR 2,000 msec./TE 60 msec. there was an increased signal intensity from the vertebral bodies and the intervertebral disk space. The other spondylodiscitis have given a different MRI imaging, it was a confluent decreased signal intensity from the vertebral bodies and the intervertebral disk space on the twice pulse sequences. different images were obtained during the evolution of the infectious: first we observed a modification of the vertebral signal then the typical image that we described then a normal signal of the vertebral bodies with a pathological signal from the intervertebral disk space at last a degenerative intervertebral disk.(ABSTRACT TRUNCATED AT 250 WORDS)     

The nocturnal jejunal migrating motor complex: defining normal ranges by study of 51 healthy adult volunteers and meta-analysis

Interdigestive human small bowel motility is characterized by the migrating motor complex (MMC). The aims of this study were to: (i) establish the normal range of variables of the nocturnal jejunal MMC and (ii) incorporate these data in a subsequent meta-analysis. Eighty-one recordings were performed by prolonged (24 h) ambulatory manometry in 51 subjects in two centres. Quantitative analysis was undertaken of 419 Phase III and 332 Phase II episodes. Adjusted mean values of seven variables were calculated using a mixed-effects model. Meta-analysis of pooled published data to generate a reliable 95% reference range was also performed. Adjusted mean values and confidence intervals are presented for all seven variables. Intrasubject variances were large in comparison with intersubject. Meta-analysis of 19 studies (356 pooled patients) meeting inclusion criteria produced wide reference ranges. At least five such ranges are useful for the detection of abnormality in the individual. This is the largest study of normal volunteers presented to date, with ranges for many variables produced using appropriate statistical methodology. A model for definition of abnormality has been proposed. We recommend that these data may be used by investigators in this field as a complement to other existing indicators of small bowel dysmotility.     

Carotid endarterectomy with internal carotid artery segmental resection, temporary shunt and vein patch angioplasty: early and mid-term results.

AIM: The authors report an alternative procedure to carotid endarterectomy with internal carotid artery (ICA) segmental resection and end-to-end anastomosis associated with temporary shunt and venous patch angioplasty. Design: prospective cohort study. METHODS: Between May 1995 and December 2004, 192 patients underwent 200 primary CEAs for significant ICA stenosis. There were 131 men and 61 women with a mean age of 72.4+/-8.4 years. The indications for CEA were asymptomatic lesions in 51.5%, transient ischemic attack in 27.5% and stroke in 21%. RESULTS: The combined early morbidity and mortality rate was 2%. Two patients died, one due to fatal intracerebral hemorrhage and the second patient died of acute mesenteric ischemia. Neurological complications occurred in 2 patients, including 1 TIA and 1 nondisabling cerebrovascular accident. Non-neurological complications occurred in 26 patients (13.5%). Seventeen patients (8.8%) developed hypertension, 3 neck hematomas (1.5%) required surgical evacuation, 1 patient had reversible supraventricular arrhythmia (0.5%) and 1 patient had pneumonia (0.5%). Furthermore, 1 asymptomatic carotid occlusion was identified (0.5%) and 3 patients suffered permanent cranial nerve injury (1.5%). Mean follow-up was 45.7 months and there were 41 late deaths (21.8%). Survival rates at 1 and 5 years were 96.7+/-1.2% and 73.58+/-4.2%, respectively. CONCLUSIONS: CEA with ICA shortening and reanastomosis is a safe and reliable procedure without any increase in morbidity or mortality.     

Activation of peripheral 5-HT4 receptors attenuates colonic sensitivity to intraluminal distension

Tegaserod is a 5-HT(4) receptor partial agonist approved for the treatment of irritable bowel syndrome in women with constipation and in both men and women with chronic constipation. The efficacy of tegaserod is based on the importance of 5-HT(4) receptors regulating intestinal peristalsis and secretion, and possibly visceral sensory pathways. Our aim was to investigate the effect of tegaserod on colorectal sensitivity using models of normal and exaggerated responsiveness to colorectal distension (CRD). The visceromotor responses (VMR) to CRD at graded pressures (0-60 mmHg) were measured by the number of reflex abdominal contractions. Acute colorectal hypersensitivity was induced by intracolonic infusion of dilute acetic acid. Chronic hypersensitivity was observed in rats following spontaneous resolution of trinitrobenzenesulfonic acid-induced colitis. Rats with normosensitive colons served as controls. Tegaserod (0.1-10 mg kg(-1)) caused dose-dependent reduction of the VMR to CRD in control rats and in those with colonic hypersensitivity. 5-HT(4) antagonists reversed the effects of tegaserod in rats with normosensitive colons, and partially inhibited effects in rats with colonic hypersensitivity. Central administration of tegaserod had no inhibitory effect. These results support the assumption that colonic hypersensitivity could be normalized by tegaserod acting, at least in part, through peripheral 5-HT(4) receptors.     

Effect of female sex hormone supplementation and withdrawal on gastrointestinal and colonic transit in postmenopausal women

Females are disproportionately affected by constipation, which is often aggravated during pregnancy. Bowel function also changes during the luteal phase of the menstrual cycle. The aim was to compare the effects of acute administration of female sex steroids on gastric emptying, small bowel transit and colonic transit in healthy postmenopausal subjects. A second aim was to determine whether withdrawal of the hormones was associated with a change in transit. Forty-nine postmenopausal females were randomized to receive for 7 days 400 mg day(-1) micronized progesterone, 0.2 mg day(-1) oestradiol, combination of the two, or placebo. Treatment groups were balanced on age. Participants underwent whole gut transit measurement by scintigraphy using a 99m-labeled technetium-egg meal and 111-labeled indium-charcoal via a delayed-release capsule. Transit measurement was repeated after withdrawal of the study medications. The primary endpoints were ascending colon (AC) emptying half-life time (t1/2) and colonic geometric centre (GC) at 24 h. Secondary analysis variables were GC at 4 and 48 h, gastric emptying t1/2 and colonic filling at 6 h. There was a significant overall effect of progesterone on colonic transit with shorter AC emptying t1/2 and significantly greater colonic GC at 48 h. No transit endpoints were altered by oestradiol or combined hormonal treatment relative to placebo. Oestradiol and progesterone resulted in looser stool consistency. Withdrawal of the hormone supplement was not associated with significant alteration in transit. Micronized progesterone does not retard colonic transit in postmenopausal females.