[Delays of treatment of acute myocardial infarction with ST elevation admitted to the CCU (coronary care unit) in Alsace]. / Délais de prise en charge de l'infarctus aigu du myocarde avec sus-décalage persistant du segment ST admis dans les USIC d'Alsace.

OBJECTIVE: to determine the time delay from symptom onset to diagnosis and treatment of patients with persistant ST segment elevation myocardial infarction (STEMI). DESIGN: prospective observational study. METHOD: patients with symptoms onset < 24 h admitted in all 10 cardiac intensive care units in one French administrative region (Alsace). Data were recorded by doctors on duty soon after hospital admission. Patients with STEMI during hospital stay or as a complication of cardiac interventional procedure were excluded. The Kruskal-Wallis test was used to assess statistical differences between the groups (p value < 0.05). RESULT: from April to October 2004, 326 patients were admitted for STEMI. Median time between the symptoms onset and the patient's call for medical help was 60 minutes. General practitioners were the first medical contact in 41%. The time from symptoms onset to first medical intervention and from first medical intervention to coronary care unit admission were markedly shorter in patients who had directly called the Emergency Medical Services (group 15-110 patients i.e. 33% of the study population): 44 min vs 75 min otherwise (p=0,003). Median transport time was 60 min. Sixty two percent of the pts were transported by the Emergency Medical Services. The median time from symptoms onset to initiation of reperfusion therapy was 240 min. It was significantly lower in group 15 (170 min vs 286 min - p < 0,001) and for thrombolytic therapy (190 min versus 245 min for primary angioplasty, p=0,007). When thrombolysis (THL) was used, 89% of the pts could be treated during 6 hours of symptoms onset and 44% in 3 hours. For angioplasty only 4% of the pts were treated in the first 90 minutes, 9% in the 2 hours and 30% in the 3 hours of symptoms onset. If the time delay is evaluated from the 1 st medical intervention, call to reperfusion intervention was significatly shorter for THL: 91 versus 157 min, p< 0,003. Angioplasty represented 75% of reperfusion strategy in our area and THL alone only 2,7% and combine therapy 5,4%. CONCLUSION: our study documents the beneficial effect of a direct call to Emergency Medical Services. Our results also underscore the need for an effort to reduce the time to offer the best appropriate reperfusion techniques in STEMI pts: speed up the admission in the cath-lab, think about pre-hospital thrombolysis followed by coronary angioplasty if necessary.

Intra-aneurysm sac pressure--the holy grail of endoluminal grafting of AAA.

OBJECTIVES: To relate intra-aneurysm sac pressure during endoluminal AAA repair to early and late endoleak, as well as to the aneurysm size upon follow-up. DESIGN: Prospective clinical investigation. METHODS AND PATIENTS: In 46 patients who had their AAAs treated by a stent graft (group I), intra-operative pressure measurement was performed (aorta uni-iliac stent grafts: 25 cases, bifurcated stent grafts: 21 cases). In 18 patients with open repair (group II) flow in the inferior mesenteric artery, and the pressure in the aneurysm sac was measured, before and after aortic and iliac cross clamping. Values are given in median with range. RESULTS: In group I, complete exclusion of AAA (no endoleak on intra-operative control angiogram) resulted in a statistically significant decrease in mean sac pressure from 74 (55-101) to 47 (4-104) mmHg. Pulse pressure reduced from 67 (34-103) to 8 (0-74) mmHg. In 11 patients a proximal type I endoleak was sealed by balloon modeling, after which the mean sac pressure reduced from 63 (14-91) to 52 (4-74) mmHg (n.s. versus patients with primary seal). Intra-operative pressure did not correlate with change in AAA diameter during twelve months follow-up. In group II, cross clamping of the proximal aorta significantly reduced mean sac pressure to 32 (21-55) mmHg, and the pulse pressure to 0 (0-13) mmHg (p < 0.05). Subsequent cross clamping of the iliac arteries did not significantly change the pressures. CONCLUSIONS: Measurement of intra-aneurysm sac pressure can help to detect and treat endoleaks during endoluminal grafting. However, the intra-operative sac pressure did not predict the fate of aneurysm during follow up. Compared to open repair of AAA, the sac pressure after endoluminal grafting remains significantly higher, in relation to pulse pressure.

Experimental and clinical evaluation of the PARIS centering catheter for delivery of endovascular gamma-irradiation of femoropopliteal stenoses.

PURPOSE: To investigate the effect of aortic bifurcation and iliac geometry on centered endovascular irradiation (CEI) of femoropopliteal arteries and evaluate procedure-related complications. MATERIALS AND METHODS: In an experimental tubing model, crossover delivery of the dummy wire by an afterloader using different sheaths (Type I: noncrossover; Type II: crossover, length 40 cm; Type III: crossover, length 65 cm) was examined at simulated angles between 20 degrees -100 degrees (aortic bifurcation) and 0 degrees -100 degrees (iliac vessels). In the clinical phase, 28 heparin-anticoagulated patients underwent percutaneous transluminal angioplasty (PTA) for femoropopliteal stenoses followed by CEI (192-iridium, 14 Gray at 2 mm depth of the vessel wall) delivered with the centering catheter (crossover from contralateral leg using a 65-cm-long 8F sheath in 13 patients, noncrossover from ipsilateral leg using a 10-cm 8F sheath in 15 patients). Measurement of the aortic bifurcation angle before advancement of the crossover sheath and rating of iliac artery tortuosity on both sides was retrospectively performed on angiograms. Fifteen controls received no post-PTA CEI. RESULTS: Experimental delivery of the dummy wire was not possible at aortic angles less than 40 degrees with Type I, 60 degrees with Type II, and 30 degrees with Type III sheaths. Advancement of the centering catheter was possible in all patients. CEI failed in two patients with crossover (aortic angle <40 degrees ) and in one obese patient with antegrade approach because advancement of the dummy wire was impossible. Thromboembolism rate was 4.6% during irradiation (2.3% after PTA alone). CONCLUSIONS: CEI in femoropopliteal arteries has a risk of procedure-related thromboembolic complications. Efficacy is affected by vessel geometry.

Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE)

OBJECTIVES: To assess (1) the short-term hemodynamic, respiratory and arterial blood gas effects of NIPSV in patients with ACPE who were likely to require endotracheal intubation, (2) the initial causes of failure and (3) the side effects and the difficulties of this technique. DESIGN: Uncontrolled, prospective clinical study. SETTING: Teaching hospital intensive care unit. PATIENTS: 26 consecutive patients with severe ACPE. INTERVENTIONS: Noninvasive ventilation via a face mask, using a pressure support mode (20.5+/-4.7 cm H2O), with an initial fractional inspired oxygen of 93.0+/-16% and a positive end-expiratory pressure of 3.5+/-2.3 cm H2O. The need to intubate the patients within 48 h was considered as a criterion of failure of the procedure. MEASUREMENTS AND RESULTS: Clinical and biological parameters were measured at 15 and 30 minutes, 1 h and 2 h and at 1 h and 2 h, respectively. There were 5 (21%) failures and 21 (79%) successes. In both the success and the failure groups, clinical and blood gas parameters improved at the first measure. In the success group, within 15 min of the start of NIPSV, pulse oximetry saturation (SpO2) had increased from 84+/-12 to 96+/-4% (p<0.001), the respiratory rate (RR) had decreased from 36+/-5.3 to 22.4+/-4.9 breaths/ min (p<0.0001) and within 1 h the arterial oxygen tension and pH, respectively, had increased from 61+/-14 to 270+/-126 mm Hg (p<0.0001) and from 7.25+/-0.11 to 7.34+/-0.07 (p<0.01) and the arterial carbon dioxide tension (PaCO2) had decreased from 54.2+/-15 to 43.4+/-6.4 mm Hg (p<0.01). There were no statistical differences between the success and failure groups for the initial clinical parameters: SpO2, RR, heart rate, mean arterial pressure. The only differences between the success and failure groups were in the PaCO2 (54.2+/-15 vs. 32+/-2.1 mm Hg, p<0.001) and the creatine kinase (CPK) (176+/-149 vs. 1282+/-2080 IU/l, p<0.05); this difference in CPK activity was related to the number of patients who had an acute myocardial infarction (AMI) (4/5 in the failure group vs. 2/21 in the success group, p<0.05). All patients with AMI in the failure group died. CONCLUSION: Among patients in acute respiratory failure, those with severe ACPE could benefit from NIPSV if they are hypercapnic, but NIPSV should be avoided in those with AMI.

[Hypertrophic obstructive cardiomyopathy in elderly patients. Retrospective study of 23 cases]. / Myocardiopathie hypertrophique et obstructive chez le sujet âgé. Etude rétrospective de 23 observations.

This retrospective study was based on data obtained from 23 patients over 65 years old (72 +/- 1.04 years) with hypertrophic obstructive cardiomyopathy followed up for 3 years (37.2 +/- 5.4 months) in whom the diagnosis was established essentially on phonomechanographic and echocardiographic criteria under basal conditions or during pharmacodynamic stress testing when the initial examination was inconclusive. Under these conditions, diagnostic catheterisation was only required in 9 cases. The incidence of this disease seems to be substantially underestimated in this age group; clinical symptoms and ECG or chest X-ray changes are often attributed to other pathologies if these patients are not thoroughly investigated. In our experience, patients over 65 years represent 20 per cent of the total population of hypertrophic obstructive cardiomyopathy admitted to our Department during the 6 years' study period. Accurate diagnosis is important because of the therapeutic implications; digitalis and vasodilator therapy especially with nitrate derivatives are poorly tolerated by these patients. Betablockers and verapamil seem to be beneficial, judged on the decrease in the number of symptomatic patients when given these drugs. Only one of the 3 deaths observed in the 20 patients followed-up was attributed to cardiac causes, which seems to confirm the lower mortality rate in older patients with this condition.

[Left intraventricular thrombosis. From diagnosis to treatment]. / Thrombose intraventriculaire gauche. Du diagnostic au traitement.

Left ventricular thrombi are the source of much concern in numerous conditions affecting the ventricles. Refinement in echocardiographic and isotopic techniques is enabling earlier diagnosis and a more rational approach to therapy. These thrombi occur very frequently, and are most often asymptomatic (more than 2 to 3 times out of 4), and their natural course is not well known. Recent studies have dealt with acute ischemic cardiopathies, but these should not obscure the fact that thrombi occur with similar frequency in chronic conditions, in particular, hypokinetic cardiomyopathies. Three recent cases emphasize this, demonstrate the frequency of these thrombi, and help illustrate available diagnostic methods and a practical approach to this condition. These recent developments only confirm the importance of effective anticoagulation in all patients at risk and the necessity of optimal treatment with inotropic agents which do not suppress thrombus formation, but appear to prevent their complications.

[The pulmonary toxicity of mercury vapors in the rat]. / Etude chez le rat de la toxicité pulmonaire des vapeurs de mercure.

Rats have been exposed for periods of 120 to 240 minutes to an atmosphere containing 6 +/- 0.7 mg per cu.m mercury vapor. All rats developed an acute respiratory distress which lead to death within 2 to 210 hours (mean 53.5 h). Microscopical examination of the lungs showed an oedema rich in fibrin, an epithelial necrosis, hyaline membranes and in two cases an interstitial fibrosis. Mercury levels in the lungs ranged between 0.5 and 9.37 micrograms per gramme wet weight. The activity of pulmonary superoxide dismutase was decreased to 1.57 +/- 0.66 micrograms per mg of soluble proteins, compared with the level of 5.01 +/- 0.76 micrograms per mg in control rats. This study confirm the pulmonary toxicity of mercury vapors observed in human intoxication.

[Acquired remissions of insulin dependence in recent diabetes mellitus. Essential prognostic factors]. / Rémissions acquises de l'insulino-dépendance de diabètes récents. Facteurs pronostiques essentiels.

24 patients with recent diabetes mellitus (less than three years) were given an intravenous insulin infusion over a short period (84 to 252 hours) in an attempt to achieve a remission of their disease through rigorous normalization of blood glucose concentrations. After this treatment, strict control of diabetes mellitus was achieved with oral mediactions in 15 of the 24 patients. In 17 cases, onset of diabetes mellitus had been sudden and insulin was required immediately (acute cetosic diabetes: ACD); in 7 patients, signs of insulin deficiency had occurred only after seven months of hyperglycemia (secondary insulin-dependent diabetes mellitus: SIDDM). A strong probability of achieving an insulin-induced remission exists only during the first six months of ACD. The success of the insulin infusion is partly dependent upon the residual beta cell function. During the remission, which lasts for more than 12 months in 50% of cases, control of diabetes mellitus is optimal.

[Maternal glucose tolerance along pregnancy (author's transl)]. / Tolérance glucosée de la femme enceinte.

The development of the foetal and placental unit induces large changes in maternal glucose tolerance along pregnancy. Oestrogen-induced hyperinsulinism is responsible for facilitated anabolism which take place during the first part of pregnancy. Accelerated catabolism occurring during the second part is due to the direct action of placental hormones, mainly of human placental lactogen. The latter is responsible for diminution of peripheral insulin activity. Hyperinsulinism, which is very important at this stage, facilitates an intense and rapid anabolism, mainly in the liver from where nutriments can be easily removed. Glucose and amino-acid uptake by placental and foetus are greatly increased by all these changes.

[Maternal glucose tolerance along pregnancy (author's transl)]. / Tolérance glucosée de la femme enceinte.

The development of the foetal and placental unit induces large changes in maternal glucose tolerance along pregnancy. Oestrogen-induced hyperinsulinism is responsible for facilitated anabolism which take place during the first part of pregnancy. Accelerated catabolism occurring during the second part is due to the direct action of placental hormones, mainly of human placental lactogen. The latter is responsible for diminution of peripheral insulin activity. Hyperinsulinism, which is very important at this stage, facilitates from where nutrients can be easily removed. Glucose and amino-acide uptake by placental and foetus are greatly increased by all these changes.