Transesophageal echocardiography-guided cardioversion of atrial fibrillation. Selection of a low-risk group for immediate cardioversion.

INTRODUCTION: In patients (pts) with atrial fibrillation (AF) of more than 48 hours' duration, electrical cardioversion (ECV) should only be performed after 3 weeks of effective anticoagulation. Transesophageal echocardiography (TEE) allows earlier ECV; however, despite exclusion of thrombi in the atrium and left atrial appendage (LAA), cases of thromboembolism related to ECV have been documented in AF. To define a low-risk group for cardioversion without previous anticoagulation, pts were selected for immediate ECV if no thrombi or dynamic spontaneous echo contrast (auto-contrast) were found after TEE and if LAA velocity was more than 0.25 m/sec. METHODS AND RESULTS: We performed TEE in 31 consecutive pts referred for ECV for AF of more than 48 hours' duration and without previous anticoagulation. After TEE the pts eligible for immediate ECV began anticoagulation with low molecular weight heparin (enoxaparin), subcutaneously in therapeutic doses, together with warfarin immediately before cardioversion. Enoxaparin was continued until an INR of over 2 was reached. Based on the TEE findings, the pts were divided in 2 groups: immediate ECV, group A, 20 pts with a mean age of 62 +/- 13 years, 6 female; and conventional therapy with warfarin before ECV, group B, 11 pts, mean age of 67 +/- 10 years (p < 0.05), 2 female. None of the pts in either group had mitral stenosis or previous episodes of thromboembolism. The mean transverse diameter of the left atrium in the 31 pts was 47 +/- 4.5 mm, without statistically significant differences between the 2 groups. Of the 11 pts in group B, 3 had a thrombus in the LAA, 6 dynamic spontaneous echo contrast and the remainder LAA velocities of less than 0.25 m/sec. ECV was achieved in all the pts, with no complications. Oral anticoagulation was maintained for at least a month. At one month, sinus rhythm was maintained in 75% of group A and 45% of group B (p < 0.01). CONCLUSION: In pts with AF of more than 48 hours' duration and no previous history of thromboembolism, the use of our exclusion criteria during TEE enabled stratification of a low-risk population for immediate ECV, which was accomplished effectively and safely in 2/3 of the pts. This strategy is associated with early symptomatic improvement, and may contribute to maintenance of sinus rhythm after one month, which was significantly better than in the pts who had prolonged therapy with warfarin before ECV, despite the differences found in age and left ventricular function.     

Infant feeding until the age of 4 months old in Seine-Maritime

This study reports infant feeding practices during the first 4 months of life. A representative sample of 10% of the births in the Seine-Maritime department formed the subject of a questionnaire cohort study carried on at home by public health institution for infants specialized nurses. Among 1,407 interviewed mothers, 52% had been thinking about their future child feeding before birth, essentially with their circles, especially their husbands. The type of feeding had been chosen before pregnancy in 64.3% of cases. Earlier choices resulted more often in breast-feeding. 46.2% of mothers tried to breast-feed their children, however 17% among them discontinued when back home. Carrying out breast-feeding (median duration 10 weeks) delayed the feeding diversification and was associated with a lower frequency of health difficulties in children.     

Catheter obstruction during prolonged parenteral alimentation. Are lipids responsible?

Catheter obstruction is a serious incident during prolonged parenteral nutrition (PN). This retrospective study was carried out in order to compare the frequencies of catheter obstruction with nutritive mixtures in bags according to whether or not lipids were mixed with the entire 24 h nutritional supply (Group I, n=33) or infused separately (Group II, n=30). Our results show that obstructions are significantly more frequent in Group I (11 13 ) than in group 2 (3 10 ), appearing within a mean interval of 29 days after inserting the catheter. The global percentages of patients undergoing cyclic PN were the same in both patient groups. In group I, however, the percentage of patients on cyclic PN was significantly higher for the obstructed catheters (100%) than for the unobstructed catheters (59%). In conclusion, the mixture of lipids with the remainder of the nutrients in the conditions of this study is the prime cause of catheter obstruction, although the exact mechanism is not elucidated. The role of cyclic PN appears to be accessory.     

Diagnostic and therapeutic management of patients with chronic inflammatory bowel disease

BACKGROUND: The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD). METHODS: Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D > 9 and D < or = 9). RESULTS: 258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group D < or = 9 and 62 (24%) to the group D > 9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D > 9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D > 9 had consulted more than one GP vs 14% (p < 0.05). Diagnosis management by the GE was the same in both groups. Patients of group D < or = 9 had more often perceived their symptoms as serious (p < 0.05). CONCLUSIONS: Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.     

Effects of latex membrane on guided regeneration of long bones

Abstract

Natural latex extracted from Hevea brasiliensis is one of the materials pointed out as potential tissue regenerators. The use of latex-based membranes in bone regeneration might be an alternative to stimulate bone formation. The aim of this study was to evaluate the effects of latex membranes in guided bone regeneration of defects produced in long bones of rats. Sixty rats were equally divided into latex and control groups, and each group was subdivided into two subgroups according to treatment duration of 1 and 4 weeks. Bone defects with 2.5?mm in diameter were surgically made in the left tibia. In the animals of the latex group, a latex membrane was placed over the bone defect. The samples underwent quantitative histological analysis of bone formation and collagen matrix, immunohistochemical analysis of osteogenic protein markers, assessment of bone mechanical properties and bone densitometry, and radiological assessment. The osteocalcin immunostaining data were submitted to the generalized linear model test with two independent factors. For the other data, the multivariate ANOVA with two independent factors was performed. The use of the latex membrane significantly improved (p?<?0.005) the volume of newly formed bone, collagen type I matrix, expression of osteopontin, and bone stiffness, both in the early and late stages of regeneration. In conclusion, the latex membrane was able to promote bone regeneration in long bones.     

Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding

AIM: The main aim of this study was to evaluate efficacy and therapeutic impact of capsule endoscopy (CE) in obscure gastrointestinal bleeding (OGIB). In addition, we evaluated the software of automatic detection of red zones (SBI, Given Imaging). PATIENTS AND METHODS: From June 2002 to June 2003, thirty-five patients with OGIB underwent capsule endoscopy after negative upper and lower digestive endoscopy. Capsule endoscopy was performed following a 12-hour fasting period and some received 2 L of PEG the night before for bowel preparation. RESULTS: CE was performed for occult (N=18) or overt (N=17) OGIB. Potentially bleeding lesions were found in 16/35 patients (45.7%). Lesions were angiodysplasias (N=8), ulcerations (N=4), tumors (N=2) and active bleeding without visible lesion (N=2). Lesions were located in gastric antrum (N=1), duodenum (N=2) and jejuno-ileum (N=13). Endoscopic (N=10), surgical (N=2) or medical (N=1) treatments were performed in 13/35 (37%). SBI was retrospectively evaluated in 24 patients with sensitivity, specificity, positive and negative predictive value of respectively 45%, 73%, 50% and 69%. CE retention during 10 days occurred in a patient with a small bowel NSAID-induced stricture. CONCLUSION: CE is a safe and effective procedure in the management of OGIB and had a therapeutic impact in more than one third of patients.     

Experimental leptospirosis in marmoset monkeys (Callithrix jacchus): a new model for studies of severe pulmonary leptospirosis

Experimental infection of marmoset monkeys (Callithrix jacchus) with Leptospira interrogans serovar Copenhageni showed microscopic patterns of tissue reactions comparable to those seen in the severe forms of human leptospirosis, including intra-alveolar hemorrhage. The most impressive microscopic changes were seen in the lung and kidney of animals killed at days 6 and 12 after inoculation. There were extensive and irregular areas of hemorrhage predominating around main bronchial branches or diffusely spread to the pulmonary parenchyma, as well as severe tubulointerstitial nephritis. Antibody response detected by the microscopic agglutination test was quantitatively similar to those seen in humans and paralleled severity of tissue lesions. The distribution of leptospires or antigenic debris in infected tissues was observed by immunofluorescence and confocal laser scanning microscopy. Large numbers of typical leptospires were seen in the lumen of proximal renal tubules. Positive reactions showing antigenic debris were closely associated with sites of tissue damage.     

Isosorbide dinitrate spray as therapeutic strategy for treatment of chronic venous ulcers

Venous ulcers are the most common form of leg ulcers, which induce lesion because of the loss of substances deposited on the damaged skin. Isosorbide dinitrate is a vasodilator with effects on both arteries and veins and induces opening of vascular layers. The objective is to study the effects of isosorbide dinitrate-spray in patients with chronic venous ulcers. Forty-five patients of both sexes with chronic venous ulcers were randomized to receive isosorbide dinitrate or placebo sprays daily for 3 months. The ulcers were measured and clinical characteristics were taken every 15 days during the treatment. Patients treated with isosorbide dinitrate showed an improvement of the ulcerated area (71.29%) compared with patients treated with placebo (54.35%). The histopathological study indicated an increment in the number of hypertrophic and hyperplasic capillaries. Macroscopically, the isosorbide dinitrate-treatment showed the best results, but it was only during the first 6 weeks of treatment. Patients with chronic venous ulcer receiving isosorbide dinitrate spray showed improvement.