[Educational and information needs of patients under vitamin K antagonist therapy]. / Quels besoins d'information et d'éducation des patients traités par les anti-vitamines K ?

BACKGROUND: Adverse events related to vitamin K antagonists (VKA) represent a major public health problem. Informative tools and educative program contributes to the reduction of iatrogenic risk. The purpose of our study is to assess representations and information needs of patients under VKA therapy in order to develop a suitable therapeutic education program. METHODS: Individual semi-structured interviews were conducted among both long term VKA therapy patient and patients initiating VKA. The thematic analysis allowed us to explore patient's speech qualitatively and semi-quantitatively. RESULTS: The main needs in information concerned the modalities of treatment (27.6%), side effects (24.1%), precautions and management of VKA treatment (24.1%). Origin of the disease (P=0.022) and drug mechanism of action (0.012) were specially asked about by patients initiating their treatment. CONCLUSION: Patients under VKA therapy reported needs for information on both their pathology and their anticoagulant therapy. The therapeutic education approach will enable us to adapt the educational tools and messages to the needs of patients under VKA therapy.

Bleeding and asymptomatic overdose in patients under Vitamin K antagonist therapy: Frequency and risk factors.

BACKGROUND: Vitamin K antagonists are widely used in the treatment and prevention of thromboembolic disease. However, these drugs can cause serious side effects, especially bleeding. This study aims to evaluate frequency and risk factors of both bleeding and asymptomatic overdose in North African patients undergoing Vitamin K antagonist therapy. METHODS: We performed a cross-sectional study in patients undergoing Vitamin K antagonist therapy. A statistical analysis has been conducted to identify overdose and bleeding risk factors by using chi-square test (p < .05). RESULTS: One hundred and eleven patients were included. We recorded 14 cases of bleeding and 26 cases of asymptomatic overdose. Advanced age, poor adherence, concomitant use of paracetamol and history of previous bleeding are significant risk factors of over-anticoagulation. An INR value over 6 at admission, a high therapeutic target range for INR, concomitant use of acetylsalicylic acid, lack of information on overdose signs and measures to be taken in case of bleeding were identified as risk factors for bleeding. CONCLUSION: Most of the risk factors identified in our study seem to be related to patients lack of information and education. These results highlight the importance of creating a therapeutic patient education program.

[Management of patients treated for acute ST-elevation myocardial infarction in Tunisia: Preliminary results of FAST-MI Tunisia Registry from Tunisian Society of Cardiology and Cardiovascular Surgery]. / Prise en charge de l'infarctus du myocarde en Tunisie : résultats préliminaires du registre FAST-MI Tunisie de la Société tunisienne de cardiologie et de chirurgie cardiovasculaire.

UNLABELLED: FAST-MI Tunisian registry was initiated by the Tunisian Society of Cardiology and Cardio-vascular Surgery to assess characteristics, management, and hospital outcomes in patients with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively collected data from 203 consecutive patients (mean age 60.3 years, 79.8 % male) with STEMI who were treated in 15 public hospitals (representing 68.2 % of Tunisian public centres treating STEMI patients) during a 3-month period at the end of 2014. The most common risk factor was tobacco (64.9 %), hypertension (38.6 %), diabetes (36.9 %) and dyslipidemia (24.6 %). RESULTS: Among these patients, 66 % received reperfusion therapy, 35 % with primary percutaneous coronary interventions (PAMI), 31 % with thrombolysis (28.6 % of them by pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 and 358 min for PAMI, respectively. The in-hospital mortality was 7.0 %. Patients enrolled in interventional centers (n=156) were more likely to receive any reperfusion therapy (19.8 % vs 44.6 %; p<0.001) than at the regional system of care with less thrombolysis (26.9 % vs 44.6 %; p=0.008) and more PAMI (52.8 % vs 8.5 %; p<0.0001). Also the in-hospital mortality was lower (6.4 % vs 9.3 %) but not significant. CONCLUSIONS: Preliminary results from FAST-MI in Tunisia show that the pharmaco- invasive strategy should be promoted in non-interventional centers.

Impact of obstructive sleep apnea in recruitment of coronary collaterality during inaugural acute myocardial infarction.

BACKGROUND: Obstructive sleep apnea (OSA) may lead to myocardial preconditioning by increasing coronary collateral vessel recruitment in patients with acute coronary occlusion. AIM: To determine the relationship between the severity of obstructive sleep apnea and coronary collaterality during acute myocardial infarction. METHODS: This study prospectively included 71 patients with an inaugural myocardial infarction who had undergone a coronary angiography within 24h of onset. All patients underwent an overnight polygraph before discharge and were classified according to the apnea-hypopnea index (AHI). Coronary collaterals were scored by visual analyses and according to the Rentrop grading system. RESULTS: Mean age was 59±11years and 83% of patients were men. All patients had complete or subtotal occlusion of the infarct-related artery. After the sleep study, patients were divided into two groups: 25 were suffering from OSA (AHI>15/h). Patients with OSA showed better collateral vessel development (Rentrop score≥1) compared to non-OSA patients (68 vs. 41%, P=0.032). AHI was significantly higher in patients with developed coronary collaterals (Rentrop≥1) compared to those without collaterality (17.74±13.2 vs. 12.24±10.9, P=0.025). CONCLUSION: Coronary collateral development may be increased in OSA patients who are presenting with a first myocardial infarction.

[Diagnostic accuracy of Epworth sleepiness scale in the acute phase of myocardial infarction]. / Intérêt du score d'Epworth à la phase aiguë d'infarctus du myocarde.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is underdiagnosed in cardiologist daily practice, especially in patients with acute coronary syndrome. Its diagnosis is based on a polysomnography study. The Epworth Sleepiness Scale (ESS) stands as a simple and rapid means to select patients for the sleep investigation. AIM: The aim of this study was to determine the diagnostic accuracy of the ESS for screening OSAS in patients with ST elevation myocardial infarction. METHODS: We conducted a prospective study of 120 consecutive patients admitted for acute myocardial infarction, from April 2011 to March 2012. Daytime sleepiness was evaluated using the ESS, when patients were in the intensive care unit. All patients have undergone an overnight sleep study using a portable diagnostic device, in the 15 days following the acute coronary syndrome. The diagnostic of OSA was considered as apnea-hypopnea index (AHI) of ≥5 events/hour, severe OSA was defined as AHI of ≥30. RESULTS: The study included 120 patients comprising 102 men and 18 women. The mean age was 58 ± 12 years. Smoking was the major cardiovascular risk factor with 72% of all patients; prevalence of diabetes was 40% and hypertension was found in 44% of the population. The prevalence of OSA was 79%. Severe OSA was diagnosed in 16% of all patients and mean AHI was 15.76 ± 14.93. Mean ESS was 2.2 ± 1.84 in the global population while it was 5.2 ± 1.2 in patients with severe OSAS. Multivariate analysis showed that ESS score ≥ 4 was an independent predictive factor for severe OSA (OR=28; 95% IC: 8-101; P<0.001). CONCLUSION: The prevalence of OSA in patients with acute myocardial infarction was very high. ESS score ≥ 4 was an independent predictive factor for severe OSA. Despite its subjective feature, the ESS seems to be an interesting score for screening patients to undergo polysomnography.

[Sudden death during sport activity in Tunisia: autopsy study in 32 cases]. / La mort subite au cours d'une activité sportive en Tunisie : à propos d'une série autopsique de 32 cas.

PURPOSE: To develop profile of the victims and to study circumstances, causes of death and autopsy findings. METHODS: Retrospective study of cases of sudden death in sport activity whose autopsy was performed in forensic department of Tunis, between January 2005 and December 2009. RESULTS: During study period, 32 cases of SD in sport activity were recorded. These are amateur athletes predominantly male (84% of cases). Victims are aged between 15 and 79 years with an average age of about 33.16 years. Young subjects whose age is less than 35 years representing 68.7% of cases. 9.3% of victims had a family history of SD and 18.7% of cases had a known cardiac history. The sports most involved are running (40.6% of cases), football (31.3% of cases) and dance (12.5% of cases). Sixty-nine percent of victims died during sports activities. Presence of witnesses was noted in all cases; however, none of these witnesses has begun resuscitation. Cause of death was cardiac in 84.4% of cases. In young athletes, hypertrophic cardiomyopathy is the leading cause (nine cases), followed by arrhythmogenic right ventricular dysplasia (three cases). Among other causes, there is the myocardial bridge, congenital anomalies of the coronary arteries, aortic dissection and dilated cardiomyopathy. Beyond 35 years, coronary artery diseases represent the cause of death (nine cases). Only case of death secondary to non-cardiac disease occurred after a severe asthma attack. In four cases (12.5%), no cause of death was identified after a complete autopsy accompanied by further investigations. The cause of the death was imputed to a rhythmic pathology. CONCLUSION: This is the first study dealing with autopsy in SD in sport have provided a specific profile of victims. Other studies on larger samples and using standardized autopsy protocols are needed.

Impedance biosensing using phages for bacteria detection: generation of dual signals as the clue for in-chip assay confirmation.

In the present work, we compare the use of antibodies (Ab) and phages as bioreceptors for bacteria biosensing by Electrochemical Impedance Spectroscopy (EIS). With this aim, both biocomponents have been immobilised in parallel onto interdigitated gold microelectrodes. The produced surfaces have been characterised by EIS and Fourier Transform Infra-Red (FTIR) Spectroscopy and have been applied to bacteria detection. Compared to immunocapture, detection using phages generates successive dual signals of opposite trend over time, which consist of an initial increase in impedance caused by bacteria capture followed by impedance decrease attributed to phage-induced lysis. Such dual signals can be easily distinguished from those caused by non-specific adsorption and/or crossbinding, which helps to circumvent one of the main drawbacks of reagentless biosensors based in a single target-binding event. The described strategy has generated specific detection of Escherichia coli in the range of 10(4)-10(7) CFU mL(-1) and minimal interference by non-target Lactobacillus. We propose that the utilisation of phages as capture biocomponent for bacteria capture and EIS detection allows in-chip signal confirmation.

Surface plasmon resonance immunosensor for bacteria detection.

This work describes an approach for the development of two bacteria biosensors based on surface plasmon resonance (SPR) technique. The first biosensor was based on functionalized gold substrate and the second one on immobilized gold nanoparticles. For the first biosensor, the gold substrate was functionalized with acid-thiol using the self-assembled monolayer technique, while the second one was functionalized with gold nanoparticles immobilized on modified gold substrate. A polyclonal anti-Escherichia coli antibody was immobilized for specific (E. coli) and non-specific (Lactobacillus) bacteria detection. Detection limit with a good reproducibility of 10(4) and 10(3) cfu mL(-1) of E. coli bacteria has been obtained for the first biosensor and for the second one respectively. A refractive index variation below 5x10(-3) due to bacteria adsorption is able to be detected. The refractive index of the multilayer structure and of the E. coli bacteria layer was estimated with a modeling software.

[Atrial flutter: a possible early sign of acute rejection in heart transplantation. A case report]. / Le flutter atrial: un témoin précoce possible du rejet aigu chez le transplanté cardiaque. A propos d'une observation.

The authors report the case of a cardiac transplant patient with a recurrence of atrial flutter two months after electrical cardioversion and despite long-term preventive treatment with amiodarone. Early investigation for signs of rejection with 4 endomyocardial biopsies was negative. Aggravation of the haemodynamic status due to flutter with a rapid ventricular response led to an attempted radio-frequency ablation. Endocavitary mapping confirmed persistence of sinus activity in the native atrium and the presence of a circuit of type I isthmic flutter (anticlockwise circuit) in the donor atrium. Ablation by radio-frequency in the same procedure was successful. A fifth myocardial biopsy the same day finally confirmed stage 3A acute rejection. No signs of recurrent rejection or arrhythmia have been observed after 24 months' follow-up in this patient. This preliminary experience confirms the need to look for graft rejection by repeated myocardial biopsies in cardiac transplant, patients with atrial flutter and the efficacy of radio-frequency ablation in cases of resistance to conventional therapy.

[Left monoplegia revealing pulmonary arteriovenous fistual in an adolescent: occclusion with an Amplatzer occluder]. / Monoplégie gauche révélatrice d'une fistule artérioveineuse pulmonaire chez un adolescent: occlusion avec un bouchon d'Amplatz.

A 16 year old adolescent was admitted to hospital for investigation of a transient left monoplegia. The clinical, electric and radiological examinations were all normal. Echocardiography showed no abnormality of cardiac structures or function. Contrast echocardiography was performed and showed a right-to-left shunt suggesting a pulmonary arteriovenous fistula which was confirmed at angiography. The fistula was closed at catheterisation by a detachable balloon: in a second procedure, the balloon was deflated and contrast studies showed a recurrence of the right-to-left shunt. An Amplatzer 8/6 duct occluder was implanted with excellent results and no recurrence at 3 months.

[Prophylactic value of automatic implantable defibrillators: a case report of a patient with asymptomatic Brugada syndrome]. / Intérêt prophylactique du défibrillateur automatique implantable: à propos d'une observation de patient ayant un syndrome de Brugada asymptomatique.

The authors report the case of an asymptomatic 32 year old man with no family history of sudden death but with ECG changes suggesting Brugada's syndrome. He underwent implantation of an automatic defibrillator after inducible syncope ventricular fibrillation had been demonstrated during electrophysiological investigation. The later occurrence of three episodes of ventricular fibrillation treated by the defibrillator confirmed a posteriori the logic of this therapeutic approach.

[Hypertension emergencies]. / Les urgences hypertensives.

Hypertensive emergencies include clinical situations with different prognosis. The emergencies are defined by the gravity of acute visceral failures. They need a parenteral treatment. Hypertensive emergency is less severe when blood pressure increase remain isolated and then is controlled progressively by oral treatment. The use of the calcium inhibitors by sublingual way is non controversies. Injectable nicardipine and uradipil represent an important progress in pharmacologic management of hypertensive emergencies.

[Infectious endocarditis caused by a glycopeptide-resistant enterococus]. / Endocardite infectieuse a entérocoque résistant aux glycopeptides.

Enterococci are an important cause of infective endocarditis. Their resistance to most of the antibiotics involve real therapeutic problems. We report the first clinical isolate of glycopeptide resistant enterococcus from blood culture of patient with a prosthetic valve endocarditis. The strain is an E. faecium with a high level of resistance to vancomycin and teicoplanin (MIC > 256 mg/l), a low level of resistance to gentamycin (MIC = 6 mg/l) and susceptible to ampicillin (MIC = 1.5 mg/l). Therapeutic failure was observed leading to a surgical treatment. Therapy of such infection caused by multiresistant Enterococcus must be based on the study of bactericidal activity of antibiotic associations. In order to control the spread of this emerging resistance, the implementation of control measures is necessary.