Prevalence of cardiac dyssynchrony and correlation with atrio-ventricular block and QRS width in dilated cardiomyopathy: an echocardiographic study.

INTRODUCTION: Cardiac dyssynchrony causes disorganised cardiac contraction, delayed wall contraction and reduced pumping efficiency. We aimed to assess the prevalence of different types of dyssynchrony in patients with dilated cardiomyopathy (DCM), and to establish the correlation between atrio-ventricular block and atrio-ventricular dyssynchrony (AVD), and between impaired intra-ventricular conduction and the existence of inter-ventricular dyssynchrony (inter-VD) and intra-left ventricular dyssynchrony (intra-LVD). METHODS: We included 40 patients in New York Heart Association stage III or IV, admitted consecutively with DCM with severe left ventricular dysfunction (left ventricular end-diastolic diameter ≥ 60 mm and/or ≥ 30 mm/m(2)) and left ventricular ejection fraction < 35%. Electrocardiographic and echocardiographic data were evaluated in all patients. Patients were divided into two groups: group 1: eight patients, with a QRS duration ≥ 120 ms, and all presented with left bundle branch block; group 2: 32 patients with a narrow QRS < 120 ms. RESULTS: Overall, the mean age was 54.7 ± 16.8 years and patients in group 1 were older (67.2 ± 13.6 vs 51.5 ± 15.8 years, p = 0.01). The prevalence of atrio-ventricular dyssynchrony (AVD), inter-VD and intra-LVD was respectively 40, 47.5 and 70%. Two patients (5%) did not exhibit dyssynchrony. AVD was present with a similar frequency in the two groups (37.5% in group 1 vs 40.6% in group 2, p = 0.8). There was no correlation of the magnitude of AVD with the duration of the PR interval (from the beginning of the P wave to the beginning of the QRS complex) (r(2) = 0.02, p = 0.37) or the QRS width (r(2) = 0.01, p = 0.38). A greater proportion of patients with inter-VD was observed in group 1 (87.5 vs 60%, p = 0.03). There was a trend towards a more important inter-ventricular mechanical delay according to QRS width (r(2) = 0.009, p = 0.06). The proportion of intra-LVD was similar in all groups, with a high prevalence (87.5% in group 1 and 65.6% in group 2, p = 0.39). CONCLUSION: The assessment of cardiac dyssynchrony is possible in our country. Intra-ventricular mechanical dyssynchrony had a high prevalence in patients with DCM, irrespective of the QRS width. These data emphasise the usefulness of echocardiography in the screening of patients.

[Prognostic value of clinical exercise testing in idiopathic pulmonary fibrosis]. / Intérêt pronostique de l'exploration fonctionnelle à l'exercice (EFX) au cours de la fibrose pulmonaire idiopathique.

Current guidelines for referring patients with idiopathic pulmonary fibrosis (IPF) for lung transplantation, based on resting parameters, are insufficient to predict 3-year mortality. The aim of this study was to determine the prognostic value of cardio-pulmonary exercise testing (CPET) in patients with IPF. A multicentre retrospective study of 3-year outcome was made on 63 adult patients with IPF who underwent CPET with blood gas analysis. Demographic data, resting pulmonary function and CPET parameters were collected to perform a univariate survival analysis. To estimate prognosis at 3 years, a multivariate logistic regression analysis by Kaplan-Meier curves and log-rank tests was performed. Forty-four patients (70%) were alive without lung transplant at the end of the 3-year follow-up: 19 patients (30%) were dead (n=14) or transplanted (n=5). Univariate analysis indicated that: at rest lower TLC, FVC, DLCO and PaCO(2), higher alveolo-arterial gradient for oxygen [P(A-a)O(2)] and pH; at ventilatory threshold (VT) higher VE/VO(2) and VE/VCO(2) and at peak exercise higher VE/VO(2) and VE/VCO(2), higher pH and ΔP(A-a)O(2)/ΔVO(2) (mmHg/L), lower VO(2) peak, PaO(2) and VO(2)/FC were associated with a significantly lower survival at 3 years. The multivariate logistic regression analysis showed that CPT (<65%) and VE/VO(2) at VT (>45) were independently associated with a lower survival at 3 years. Restriction and hyperventilation at ventilatory threshold are major prognostic factors in the course of IPF. CPET with blood gas analysis may have a prognostic value in these patients and initial evaluation of these parameters can help to predict disease progression.

[Diagnosis of tuberculous uveitis: clinical application of an interferon-gamma release assay]. / Diagnostic des uvéites tuberculeuses: intérêt des tests interférons gamma.

M. tuberculosis is a possible cause of uveitis; the diagnosis is often difficult. The aim of this study is to evaluate, in this context, the application of an interferon gamma assay, the SpotTB™. The prospective study, in patients presenting with uveitis without obvious cause and not resolving with local treatment, compared the therapeutic approach (giving antituberculous treatment or not) with and without the result of the SpotTB™. The analyses included 23 patients: 78% had received BCG; 78% had isolated ocular involvement; 22% had associated mediastinal lymphadenopathy. The results of the IDR and the SpotTB™ were concordant in 61%, discordant in 22% and non-evaluable in 17% of cases. In the patients with isolated ocular involvement the SpotTB™ avoided treatment in five and reinforced the decision not to treat in 13 others. In the patients with mediastinal lymphadenopathy, the SpotTB™ reinforced the diagnosis of sarcoidosis in four cases (one lost from view). In conclusion, when infection with M. tuberculosis is considered in the aetiology of uveitis the SpotTB™ allows, in a significant number of cases, the avoidance of antituberculous treatment.

[Management of acute exacerbations of COPD]. / Prise en charge des exacerbations aiguës de BPCO.

Exacerbations of COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated oxygen therapy, inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents), DVT prevention with LMWH, steroids in most severely ill patients, unless there are contraindications and antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to acute hypercapnic respiratory failure. Unless contraindicated, non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of COPD, demonstrating a decreased need for mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values>7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory. Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV. The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients. hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations, nutritional support, and pulmonary rehabilitation.

[Search for lesions caused by aflatoxin B1 poisoning in 3 industrial chicken farms on the Ivory Coast]. / Recherche dans trois élevages industriels de poules en Côte-d'Ivoire des lésions de l'intoxication par l'aflatoxine B1.

A systematic search for feed contamination by aflatoxin-B1 as well as for lesions indicating an acute or chronic aflatoxicosis was made in three groups of industrially raised hens in Côte-d'Ivoire. The contamination rates were low although they were 6 to 10 times higher than the official standards. No lesion due to an acute or chronic intoxication by aflatoxins was observed. However, the repeated intake of small amounts of aflatoxins might eventually have repercussions on the technics-economical performance either by a direct action of the toxin or via the development of an immune depression in the animals.