Impact of myocardial injury after coronary artery bypass grafting on long-term prognosis.

AIMS: The most appropriate definition of perioperative myocardial infarction (pMI) after coronary artery bypass grafting (CABG) and its impact on clinically relevant long-term events is controversial. We aimed to (i) analyse the incidence of pMI depending on various current definitions in a 'real-life' setting of CABG surgery and (ii) determine the long-term prognosis of patients with pMI depending on current definitions. METHODS AND RESULTS: A consecutive cohort of 2829 coronary artery disease patients undergoing CABG from two tertiary university centres with the presence of serial perioperative cardiac biomarker measurements (cardiac troponin and creatine kinase-myocardial band) were retrospectively analysed. The incidence and prognostic impact of pMI were assessed according to (i) the 4th Universal Definition of Myocardial Infarction (4UD), (ii) the definition of the Society for Cardiovascular Angiography and Interventions (SCAI), and (iii) the Academic Research Consortium (ARC). The primary endpoint of this study was a composite of myocardial infarction, all-cause death, and repeat revascularization; secondary endpoints were mortality at 30 days and during 5-year follow-up. There was a significant difference in the occurrence of pMI (49.5% SCAI vs. 2.9% 4UD vs. 2.6% ARC). The 4th Universal Definition of Myocardial Infarction and ARC criteria remained strong independent predictors of all-cause mortality at 30 days [4UD: odds ratio (OR) 12.18; 95% confidence interval (CI) 5.00-29.67; P < 0.001; ARC: OR 13.16; 95% CI 5.41-32.00; P < 0.001] and 5 years [4UD: hazard ratio (HR) 2.13; 95% CI 1.19-3.81; P = 0.011; ARC: HR 2.23; 95% CI 1.21-4.09; P = 0.010]. Moreover, the occurrence of new perioperative electrocardiographic changes was prognostic of both primary and secondary endpoints. CONCLUSION: Incidence and prognosis of pMI differ markedly depending on the underlying definition of myocardial infarction for patients undergoing CABG. Isolated biomarker release-based definitions (such as troponin) were not associated with pMI relevant to prognosis. Additional signs of ischaemia detected by new electrocardiographic abnormalities, regional wall motion abnormalities, or coronary angiography should result in rapid action in everyday clinical practice.

Cerebellar haemorrhage mimicking acute peripheral vestibulopathy: the role of the video head impulse test in differential diagnosis.

Dizziness and vertigo without neurological signs are typically due to a peripheral vestibular disease. Although the most common causes are benign, differential diagnosis must include potentially life-threatening central diseases such as cerebrovascular pathologies. A systemic clinical approach needs a careful work-up, bedside examination and appropriate instrumental investigation. The head impulse test (HIT) allows qualitative clinical assessment of canalar function; it has some limitations such as subjective evaluation, mainly in patients with a spontaneous nystagmus. A new device has been recently developed consisting of an infrared video camera (video-HIT) to provide quantitative instrumental assessment of the high-frequency vestibular-ocular reflex (VOR) gain. By reporting a case of cerebellar haemorrhage mimicking an acute peripheral vestibulopathy, the authors suggest that video-HIT may be considered a useful tool in differential diagnosis between vestibular neuritis and cerebellar vascular disease in patients with severe acute vertigo without central signs.

Vestibular function outcomes after vestibular neurectomy in Meniere disease: can vestibular neurectomy provide complete vestibular deafferentation?

OBJECTIVE: Vestibular neurectomy is considered the reference treatment of incapacitating vertigo accompanying Meniere disease, with an efficiency rate of 85-95% in most literature reports. The aim of this study is to evaluate if vestibular neurectomy can provide a complete vestibular deafferentation by investigating complete vestibular function after surgery. METHODS: Prospective study. Twenty-four patients suffering from incapacitated Meniere vertigo crisis beneficiated from a vestibular neurectomy by retrosigmoid approach. The average time between surgery and vestibular evaluation was 1 year. We performed (i) kinetic test, (ii) caloric test and (iii) vibration-induced nystagmus (VIN) at 30, 60 and 100Hz under videonystagmography recording, (iv) vestibular evoked myogenic potentials (VEMP), (v) video head impulsed test (VHIT) for each semicircular canals and (vi) an evaluation of visual vertical and horizontal subjective (VVS and HVS). RESULTS: On clinical evaluation, all the patients except one had never experienced any recurrence of vertigo crisis after surgery. The 24 patients would definitely undergo the surgery again. On vestibular evaluation, on the operated side, all patients showed a total areflexia at caloric test; 23 patients had no VEMP response; 23 patients had abolished canals response to VHIT. All the patients had VVS and HVS deviated towards the operated side; 23 patients had a high velocity VIN from 30 to 60Hz. CONCLUSION: This study proves that vestibular neurectomy can provide a complete vestibular deafferentation. We discuss this vestibular evaluation protocol and the main difficulties encounter during surgery, which could lead to partial nerve section and partial relief, and explain residual vestibular function after vestibular neurectomy.

[Skull vibration induced nystagmus test]. / Le test vibratoire osseux vestibulaire.

OBJECTIVES: To establish during a consensus meeting the fundamental basis, the validity criteria, the main indications and results of the skull vibration induced nystagmus test (SVINT) which explores the vestibule high frequencies. MATERIAL AND METHODS: The SVINT is applied on the mastoid process (right and left sides) at 100 Hz during 10 seconds on a sitting upright subject. Total unilateral peripheral lesions (tUVL: operated vestibular shwannomas, vestibular neurectomies) and partial unilateral peripheral lesions (pUVL: preoperative neuromas, Meniere's disease, vestibular neuritis, chemical labyrinthectomies) were studied. Thirty-six patients had brainstem lesions and 173 normal subjects were used as controls. RESULTS: The SVINT is considered positive when the application of the vibrator produces a reproducible sustained nystagmus always beating in the same direction following several trials in various stimulation topographies (on the right and left mastoid). The skull vibratory nystagmus (SVN) begins and ends with the stimulation; the direction of the nystagmus has no secondary reversal. The slow phase velocity (SPV) is>2 degrees /second. In tUVL the SVINT always reveals a lesional nystagmus beating toward the safe side at all frequencies. The mean SVN SPV is 10.8 degrees /s+/-7.5 SD (N=45). The mastoid site was more efficient than the cervical or vertex sites. Mastoïd stimulation efficiency is not correlated with the side of stimulation. The SVN SPV is correlated with the total caloric efficiency on the healthy ear. In pUVL the SVINT is positive in 71 to 76% of cases; the mean SVN. SPV (6.7 degrees /s+/-4.7 SD)(N=30) is significantly lower than in tUVL (P=0.0004). SVINT is positive in 6 to 10% of the normal population, 31% of brain stem lesions and negative in total bilateral vestibular peripheral lesions. CONCLUSIONS: SVINT is an effective, rapid and non invasive test used to detect vestibular asymmetry between 20 to 150 Hz stimulation. This test used in important cohorts of patients during the ten last years has demonstrated no observable adverse effect. SVINT complements other tests which evaluate lower frequencies (caloric test: 0,003 Hz) and the medium frequencies (Head-Shaking-Test (HST): 2 Hz; the head impulse test (HIT): 6 Hz). SVINT is useful in the diagnosis of labyrinthine hydrops or detection of acoustic neuromas. It is useful when the caloric test can not be practised because of middle ear problems. SVINT has its limits: in pUVL, the nystagmus direction is not always specific of the pathologic side and can change with the stimulus frequency. This test does not precisely point out the level of the lesion on the vestibular pathway.

[Curthoys and Halmagyi Head Impulse test: an analytical device]. / "Head Impulse test de Curthoys & Halmagyi". Un dispositif d'analyse.

UNLABELLED: Described in 1988 by Curthoys and Halmagyi, the Head Impulse test enables checking the individual response of each of the six semicircular canals to fast head movements within less than one minute. Interpretation of test results requires careful clinical observation of the eye/head synchronism. But, due to the very short duration of the phenomenon, such synchronism is often difficult to confirm. This is so difficult that, sixteen years after its first description, the test is still rarely performed in daily practice. OBJECTIVES: We describe hereafter a device which allows confirmation of the positive or negative test results for each of the six canals without increasing test duration. METHOD: A high resolution and high light sensitivity video camera located in front of the patient's face at a distance of 80 cm is connected to a computer for automatic image analysis. RESULTS: With this device, the practitioner can confirm a positive test by simple observation on the videooculocephaloscope (HIT scope) and record an image for later reference. With videooculocephalography (HIT graph), movements can be recorded for analysis to quantify the deficit of each semicircular canal.

[Vibration-induced nystagmus: mechanism and clinical interest]. / Nystagmus induit par des vibrations: physiopathogénie et intérêt en clinique.

UNLABELLED: In 1973 Lücke described nystagmus induced by application of a vibrator on the mastoid process. Since that time, several Authors have applied the vibrator test in normal subjects or patients suffering from various well-characterized conditions. OBJECTIVE: Recognizing that results obtained with the vibrator test are sometimes in contradiction with those of other vestibular tests, our aim was to formulate an assumption regarding the genesis of induced nystagmus in an attempt to explain such contradictions. MATERIAL AND METHODS: We considered seven very different clinical situations. Each patient underwent a standard protocol including pendular and caloric tests as well as the vibrator test. We sought an assumption allowing, i) an interpretation of the characteristic features of nystagmus induced by the vibrator in any situation, ii) an understanding of the reasons why some vibrator test results do not correlate with those of other vestibular tests. RESULTS AND CONCLUSION: We assume that the vibrator stimulates phasic cells of the cupula and the vestibular maculae preferentially, if not exclusively. This assumption allows us to retain a very simple protocol for the vibrator test useful for routine clinical practice.

[Bilateral vestibular areflexia: quantification is required]. / Aréflexie vestibulaire bilatérale: une notion toute relative.

Bilateral vestibular loss, that should be more precisely qualified as "horizontal semicircular canal bilateral loss", is a concept usually defined by the following characteristics: - no response to caloric tests, - no response to pendular test with a 20-second period, - increasing gain of the cervico-ocular reflex. We present five cases. We increased the stimulation frequency to a level higher than usually, employed and observed that: - at a given frequency threshold a certain amount of reactivity may be observed, - above that threshold the reactivity increases in proportion with stimulation frequency. The apparent vestibular loss is actually related to stimulation frequency. This phenomenon could be explained by considering the physiology of phasic and tonic cells.

[Disorders in gaze saccades in Huntington disease. Clinical correlations]. / Störung der Blicksakkaden bei der Huntington-Krankheit. Klinische Korrelationen.

Oculomotor abnormalities have long been recognized in Huntington's disease (HD). The precise correlation between them and other clinical findings has not yet been determined. Using videonystagmography, we studied reflexive, visually guided horizontal saccades in 32 patients with genetically confirmed HD: nine female and 23 male patients, including six with young onset HD (YOHD), 19 with adult onset HD (AOD), and seven with late onset HD (LOHD). Huntington's patients exhibited increased saccade latency (P < 0.05), decreased saccade velocity (P < 0.0005), and impaired saccade accuracy (P < 0.01). A significant difference between the different groups of patients could be determined, and YOHD was characterized by normal latency and decreased saccade velocity while LOHD showed increased saccade latency but normal velocity. Furthermore, we found a significant difference between the genetic data (length of CAG-repeats) and saccadic abnormalities, with higher repeat numbers corresponding to shorter latency and decreased velocity, as in YOHD. The study of saccade parameters might be useful as an objective method for testing the effectiveness of future therapies.

[Speed of ocular saccades in Huntington disease. Prospective study]. / Velocidad de las sacadas oculares en la enfermedad de Huntington. Estudio prospectivo.

BACKGROUND: Oculomotor abnormalities, especially slow saccades, have long been recognized in Huntington's disease (HD). OBJECTIVES AND METHODS: To study prospectively horizontal saccade velocity by videonystagmography in 21 patients with genetically confirmed HD. The study included a baseline analysis and a second evaluation after 18.8 +/- 7.1 months. We included a control group of 15 subjects. RESULTS: HD group exhibited decreased saccade velocity when compared with that from a control group (for predictive and unpredictive target). HD patients showed decreased saccade velocity with the passage of time (for predictive target, p < 0.01). Finally we found statistical significant correlation between saccade velocity and triplet length. CONCLUSIONS: The measurement of saccade velocity might be an objective method to study the natural evolution of HD, and thus evaluate the effectiveness of future therapies.

Velocidad de las sacadas oculares en la enfermedad de huntington. Estudio prospectivo / Speed of ocular saccades in Huntington's disease. Prospective study

FUNDAMENTO: Las perturbaciones oculomotoras son muy frecuentes en la enfermedad de Huntington (EH). Probablemente la caída de la velocidad sacádica es el hallazgo más característico desde el punto de vista neuroftalmológico. OBJETIVOS Y MÉTODOS: Estudiar prospectivamente la velocidad de las sacadas horizontales mediante videonistagmografía en 21 pacientes con EH confirmada genéticamente. Se realizó el mismo protocolo en la primera evaluación (tiempo 0) y en la de seguimiento (18,8 ñ 7,1 meses después). Se incluyó un grupo control de 15 individuos sin enfermedad neurológica. RESULTADOS: Los pacientes con EH presentaron una velocidad horizontal sacádica inferior a los controles, tanto para estímulo predecible como no predecible. Además, en el seguimiento manifestaron un deterioro significativo de la velocidad sacádica horizontal (p < 0,01; para estímulo predecible).Asimismo hubo correlación significativa entre la expansión de tripletes y la velocidad sacádica. CONCLUSIÓN: El estudio de la velocidad sacádica podría servir como método objetivo de seguimiento de la EH, especialmente en relación con el empleo de futuras terapias neuroprotectoras (AU)

[Using interaction-intensive therapeutic nursing measures and "home remedies" in nursing care. An explorative study as a plea for integrated nursing practice]. / Der Einsatz von interaktionsintensiven pflegetherapeutischen Massnahmen und von "Hausmitteln" in der Pflege. Eine explorative Studie als Plädoyer für eine integrierte Pflegepraxis.

BACKGROUND: Until today there existed no major studies about the wide range of currently utilized methods or potential sociodemographic and institutional influences on utilization despite an immense interest among nurses in alternative nursing methods (in this study referred to as home remedies). METHODS: In this study, from standardized questionnaires with a convenience sample of three different settings of nursing practice, i.e. acute-care, nursing homes, and home health care were analyzed using the statistical program SPSS. RESULTS: Our analysis showed that a wide range of traditional home remedies is being utilized, e.g. application of heat and cold or herbal infusion (herbal teas). Furthermore, lay approaches such as aromatherapy were also commonly used. The statistical analysis revealed complex influences of age, duration of nursing practice and institutional setting in the utilization of home remedies. CONCLUSION: There is need for more systematic studies to further examine the alternative methods or home remedies so popular among nurses and their patients. Regarding a more consistent naming of the variety of different methods coming from naturopathy, folk and lay medicine, the authors suggest the term "integrative nursing care".

[Eating and drinking in patients with Alzheimer dementia. A study of interactions]. / Essen und Trinken bei Menschen mit Alzheimer-Demenz. Eine Interaktionsstudie.

Eating and drinking become difficult for people afflicted with dementia. We have therefore analysed the mealtime constellation in five cases of institutionalised people suffering from Alzheimer using video in an open technique. The process of eating and drinking entailed intensive interaction between patients and their nurses. The demented were apparently in possession of extensive nonverbal communicative ability to both transmit and receive signals. It proved possible to identify behavioral factors that hinder or benefit the mealtime procedure of the analysed cases.