Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age ±SD was 33 ± 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 ± 7 to 6 ± 4 mm Hg, mean left atrial pressure decreased from 27 ± 8 to 15 ± 6 mm Hg, cardiac index increased from 3.0 ± 0.7 to 3.6 ± 0.8 L/min/m², and Gorlin mitral valve area, from 0.97 ± 0.19 to 2.2 ± 0.4 cm² (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 ±0.18 to 2.15 ± 0.36 cm² (p < 0.00001). A final valve area of ≥1.5 cm² was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area <0.8 cm² and an echocardiographic score (echo score) ≥12 as the strongest predictors of residual stenosis (final mitral valve area <1.5 cm²). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio ≥1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 ± 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area <1.5 cm²) occurred in 10.4% of patients. The 3-year Kaplan-Meier freedom from restenosis was 92%, and from reintervention 93%. Because fluoroscopic calcium and postprocedure mitral valve area <-1.8 cm² were the independent predictors of restenosis, patients with calcified valves should be selected for this procedure on a case-to-case basis.     

Biological variation of holotranscobalamin and cobalamin in healthy individuals

Data on biological variation for cobalamin and holotranscobalamin (holoTC) are limited. The aim of this study was to determine within-subject (CV_I) and between-subject (CV_G) biological variations for these analytes in a healthy population. We collected blood samples from 15 healthy volunteers (12 women and three men, 22–66 years) on the same weekday for 10 consecutive weeks. Serum samples were stored at –80?°C until analysis in duplicate in a single analytical run. The CV_I and CV_G were estimated by nested ANOVA. The CV_I (95% CI) for cobalamin and holoTC was 6.7% (5.7–7.7) and 13.0% (11.5–15.0), respectively. The corresponding CV_G was 24.1% (16.4–36.0) and 24.6% (16.3–37.7). The analytical variation (CV_A) (95% CI) was 3.5% (3.2–4.0) for cobalamin and 2.4% (2.1–2.6) for holoTC. The index of individuality (II) was low (<0.6) for both cobalamin and holoTC and the reference change value (RCV) was 20.1% for cobalamin and 36.6% for holoTC. Our study describes the components of biological variation of cobalamin and holoTC in a healthy population, contributing to a better clinical interpretation of these biomarkers.     

Long chain fatty acid (Lcfa) abnormalities in hyper Igd syndrome (Hids) and familial Mediterranean fever (Fmf): New insight into heritable periodic fevers

ObjectiveTo examine essential fatty acids (EFAs) in hyper-IgD syndrome (HIDS) and Familial Mediterranean Fever (FMF).MethodsEFAs were determined in sera derived from an archival, cross-sectional group of HIDS/FMF patients, stratified for presence and absence of fever. Control populations included healthy afebrile adults, and individuals with non-periodic fever (septic shock). EFAs were quantified using isotope dilution gas chromatography–mass spectrometry and data analyzed employing a Kruskal–Wallis non-parametric ANOVA with Dunn's post-hoc test.ResultsSera samples derived from HIDS patients showed significantly decreased C20, C26, phytanic and pristanic acids during febrile crises that normalized in the afebrile state, and a significantly increased afebrile C22_4ω6 level that normalized with fever. Samples derived from FMF patients revealed increased ω-oxidized LCFAs as compared to controls, and the trend was for these same species to be increased in comparison to febrile, but not afebrile, HIDS patients. Individuals with non-periodic fever demonstrated global decreases in C10–C24 fatty acids, both saturated and unsaturated, accompanied by an elevated triene/tetraene ratio.ConclusionsOur results suggest that different mechanisms are active in hereditary periodic fever syndromes that appear unrelated to fever, including depletion of very long chain fatty acids (VLCFAs) in febrile HIDS patients and increased ω-oxidized LCFAs in patients with FMF. These findings underscore new roles for EFAs in the potential production of inflammatory species in patients with hereditary periodic fever.     

Making Neonatal Intensive Care Units More Visually Appealing

A neonatal intensive care unit (NICU) provides a series of impressions that impact behavior and attitudes of staff, families, visitors, and donors. The value of incorporating nature, artistic features, daylight, creative themes, and special furnishings should not be diminished. These efforts have the potential to support families' ability to cope, increase job satisfaction, increase donor appeal, and enhance recruitment. Clear guiding principles, research, and a collaborative process are essential to creating and maintaining a visually appealing NICU that makes these types of differences.     

Peripheral administration of antithymocyte globulins: A review of current literature

Antithymocyte globulin (ATG) preparations are purified gamma-immune globulin products used for the prevention and treatment of transplant organ rejection. Manufacturer labeling recommends administration of the currently available ATG preparations (rabbit antithymocyte globulin and equine antithymocyte globulin) via a high-flow vein; typically this is achieved through a central line. The necessity of maintaining central-line access may delay or prevent the administration of these products and place patients at increased risk of morbidity. Currently, there is limited information on the peripheral administration of ATG preparations. However, data suggest that peripheral administration of ATG is both safe and well tolerated. Peripheral administration of ATG may allow for stable low-risk patients to transition to the outpatient setting, thereby, reducing costs and risks associated with hospitalization. This article reviews the available literature on the safety of peripheral administration of ATG preparations, the clinical considerations, and potential economic implications.     

Completeness of malaria notification in Tunisia assessed by capture recapture method

ObjectiveTo estimate the completeness of malaria notification to the public healthcare system (PHCS) and to describe retrospectively data of malaria cases in Tunisia.MethodsWe conducted a retrospective epidemiological survey using a standardized questionnaire for all cases of malaria reported to PHCS and those diagnosed in parasitological laboratory or infectious disease service between January 2002 and December 2007. To estimate the total number of cases, we used a two sources capture-recapture analysis.ResultsAfter record-linkage and cross-validation 317 cases of malaria were identified, of whom 231 were notified, resulting in an observed under-notification of 17%. The estimated number of malaria cases using capture-recapture analysis was 366.3 (95% CI: 335.8-396.8) for the period of study with a completeness of 63.1% which increased from 44.8% for 2002 to 78.7% for 2007. One hundred and sixty two patients (51.1%) had been born in sub-Saharan Africa, 113 (35.6%) in Tunisia, 35 (11.0%) in North Africa and 7 (2.2%) in Europe with predominance of men (87.1% of all cases). The median age was 25.0 years (21-30) for sub-Saharan Africans, 38.0 years (23.5-45.5) for North Africans, 38.5 years (30.75-38.5) for Tunisian and 39.0 (26-43) for European (P<0.01). The most predominant malaria species was Plasmodium falciparum with 216 cases (72.5%), and the most frequent area of acquisition was sub-Saharan Africa. In our study, information on compliance with malaria prophylaxis was only sporadically available and 34% of infected individuals had not used any chemoprophylaxis. Our study showed delayed identification of malaria that indicated a deficit in medical awareness and management of this infection.ConclusionsOur survey has marked variety in the type and availability of key data and shown an underreporting of malaria cases. Furthermore, it demonstrates that the two different sources of malaria registration are substantially incomplete. Of particular interest is the observation that a considerable number of patients could only be found in the records of PHCS, they were unknown to the laboratories, although malaria confirmation by thick or thin smear is obligatory in Tunisia.     

IORT with Electrons as Boost Strategy during Breast Conserving Therapy in Limited Stage Breast Cancer: Results of an ISIORT Pooled Analysis

Strahlentherapie und Onkologie -