[Can the rate of episiotomy still be lowered? Status update in PACA region (south of France)]. / Peut-on encore diminuer le taux d'épisiotomie ? État des lieux en région PACA.

OBJECTIVE: To evaluate professional practices relative to episiotomies in the Provence Alpes Côte d'Azur (PACA) region by analysing their incidence in maternity hospitals, by type and by sector of activity. Following this, to analyse maternal and obstetric characteristics associated with episiotomies and the occurrence of perineal tears in Marseille's university hospitals (CHU). METHODS: Data were extracted from the database for the period from 1st January 2012 to 31 December 2014. The sample included 41 maternity hospitals: 13 private and 28 public. Twenty of the maternity hospitals were level 1, 15 were level 2, and 2 were level 3 (Nice and AP-HM). RESULTS: In the PACA region, 176,573 patients gave birth by vaginal delivery. The incidence of episiotomy over the 3 years was 21.6% (0.50% - 76.13%) with a statistically significant reduction in the incidence between 2012 and 2014 (P<0.001). There was a significant difference by sector (P<0.001) and level (P<0.001) of maternity hospitals. In the Marseille CHU, 21.6% of women had an episiotomy (66.4% in primiparas - 33.6% in multiparous) and 43% had perineal tears (62.3% in primiparas - 37.7% in multiparous). After multivariate analysis, gender, weight of the newborn, presentation, gestational age, and mode of delivery were shown to be factors significantly associated with occurrence of episiotomy and occurrence of perineal tear (P<0.001). CONCLUSION: A significant decrease in the incidence of episiotomy was observed in the PACA region from 2012 to 2014, associated with a wide variation in rates depending on the maternity hospitals, their types and their sectors.

Relationship between the Level of Education and Functional Capacity in Active Elderly Adults.

BACKGROUND: Both the level of education and functional capacity seems to be associated with the level of physical activity in the elderly. However, the relationship between the level of education and functional capacity in active elderly adults is poorly understood. OBJECTIVE: To examine the association between the level of education and the functional capacity profile of active elderly adults. DESIGN: Cross-sectional. PARTICIPANTS: One hundred and four elderly men and 198 postmenauposal women (mean age: 62.7 ± 7.6 years old) were recruited among registered members of the YMCAs of Montreal who practiced at least one hour of structured physical activity per week. Participants were then divided in two groups based on their level of education (the cut-off point was the high-school diploma). MEASUREMENTS: Body composition (DXA), muscle strength (knee extensors, handgrip), estimated maximal oxygen consumption (2-km walk test), perceived health (SF-36) and functional capacity (timed up and go, alternate step and one-leg stance tests) were measured. The level of education of the participants was assessed by questionnaire. RESULTS: Body composition was similar between groups. We observed that all functional capacity tests as well as the global functional capacity score were significantly higher in the most educated group compared to the least educated group (p<0.05). In addition, the most educated group had significantly higher levels of knee extensors strength, estimated maximal oxygen consumption and perception of physical functioning. CONCLUSIONS: A higher level of education was associated with a favourable functional capacity profile in our cohort of active elderly adults. However, the mechanism(s) which could mediate this association remain(s) unknown.

Anxiety and depression in psychogenic movement disorder and non-epileptic seizures: a prospective comparative study.

OBJECTIVE: This study compared anxiety and depression in patients presenting with psychogenic non-epileptic seizures (PNES) with those suffering from psychogenic movement disorders (PMD) to assess the link between these psychiatric pathologies and neurological symptoms. METHODS: This clinically descriptive, prospective study involved consecutive patients who fulfilled the clinical and video-EEG criteria for PNES and PMD, and who were recruited over an 18-month period. Semi-structured (according to DSM-IV criteria) psychiatric interviews and self-evaluation using the Beck Depression Inventory and Spielberger State-Trait Anxiety Inventory were carried out. Clinical follow-up was conducted 8-12 months after the first evaluation. RESULTS: A total of 17 patients were recruited: nine presented with PNES; and eight had PMD. Both patient groups had similar demographic and clinical data as well as depression and personality disorders. Although not statistically significant, there was a trend towards an increased prevalence of a familial medical history of epilepsy and a higher incidence of anxiety disorders among patients with PNES. CONCLUSION: The data from this prospective study underscore the clinical and psychiatric similarity between PNES and PMD patients. Further studies involving a larger number of subjects should confirm, from a statistical point of view, the differences suggested in the present investigation and, in particular, the greater incidence of anxiety disorders in PNES patients and the presence of an epileptic parent as a risk factor for PNES.

Efficacy of Viabahn in the treatment of severe superficial femoral artery lesions: which factors influence long-term patency?

PURPOSE: To evaluate superficial femoral artery (SFA) occlusive disease treatment by means of covered stents. STUDY DESIGN: retrospective. METHOD: From 2000 to 2005, a Hemobahn/Viabahn endoprosthesis was implanted in 102 limbs (95 patients; mean age: 72.1 years, 52-94) for intermittent claudication (group I, n=50 limbs), critical (group II, n=32) or acute ischemia (group III, n=20). Lesions treated were Trans-Atlantic Inter-Society Consensus (TASC) A (n=9) B (n=42), C (n=28) or D (n=23), associated with a good (2 or 3 leg arteries, n=60) or a poor (1 or 0 artery, n=42) runoff. RESULTS: The endograft was placed successfully in all cases, but 3 early deaths (3.2%) (1 in group II and 2 in group III), and 4 acute thromboses (4%) occurred. Primary and secondary actuarial patency rates were 97+/-1.7%, and 99+/-1% at 1 month, 74+/-4.8% & 84+/-4.1% at 1 year,and 71+/-9.5% & 79+/-8.5% at 3 years, after a mean follow-up of 30.2 months (1-60). Long-term primary and secondary patencies were significantly different between TASC Cand TASC D lesions (P<.004 & .001). CONCLUSION: Severity of lesions, rather than preoperative symptoms or runoff, is mainly to be considered before using Hemobahn/Viabahn endoprosthesis in severe SFA occlusive lesions.

Rapid molecular diagnosis of tuberculosis and other mycobacteriosis in smear-negative clinical specimens

Delay in diagnosis of pulmonary and other forms of tuberculosis (TB) can be fatal, particularly in HIV-infected patients. Hence, techniques based on nucleic acid amplification, which are both rapid and of high specificity and sensitivity, are now widely used and recommended for laboratories that diagnose TB. In the present study, diagnostic methods based on mycobacterial DNA amplification were evaluated in comparative trials alongside tradicional bacterial methods, using negative smear samples from patients with clinically-suspected TB (sputum samples from 25 patients with suspected pulmonary TB, urine samples from two patients with suspected renal TB and cerebrospinal fluid samples from one patient with suspected meningeal TB). A specificity of 100% was achieved with DNA amplification methods and tradicional culture/identification methods, in relation to clinical findings and treatment results. For the smear-negative sputa, conventional PCR for M.tuberculosis was positive in 62% of suspected lung TB case, showing the same sensitivity as bacterial identification. Both techniques failed in the detection of extra-pulmonary samples. Nested PCR showed, after species-specific amplification, a sensitivity of 100% for M. avium and 85% for M. tuberculosis. For extra-pulmonary smear-negative samples, only Nested PCR detected M. tuberculosis and all cases were confirmed clinically. Nested PCR, in which two-step amplification reactions are performed, can identify the two most important mycobacteria in human pathology quickly and directly from clinical spicimens

Efficacy of Hemobahn in the treatment of superficial femoral artery lesions in patients with acute or critical ischemia: a comparative study with claudicants.

PURPOSE: To assess the results of covered stents in the treatment of superficial femoral artery (SFA) occlusive disease. METHOD: From July 2000 till June 2003, 32 patients (34 limbs) were scheduled for procedures including Hemobahn deployment in the SFA. Indication for treatment was claudication (group I, N=15 patients and 16 limbs, 31.2% occlusions) or critical and acute ischemia (group II, N=17 patients and 18 limbs, 61.1% occlusions). TASC D SFA lesions were excluded. No limb artery was patent pre-operatively in 19% and 89% of limbs in groups I and II, respectively (p=0.00001). RESULTS: Outflow procedures were performed simultaneously in one limb in group I and 12 in group II (p=0.0003). The technical, hemodynamic and clinical success rates were 100, 100 and 94.1%, respectively. Mean follow-up was 18.1 months. Primary patency rates at 12 months were 81.3+/-10.6% in group I and 88.6+/-9.0% in group II (p=0.547). At 12 months, the secondary patency and limb salvage rates were, respectively, 87.5+/-8.9 and 100% in group I and 87.5+/-8.93 and 94.45+/-6.71% in group II. CONCLUSION: Treatment of SFA occlusive lesions (excluding TASC D lesions) with the Hemobahn covered stent yielded good results for both claudicants with good outflow and patients with critical or acute ischemia with bad outflow, if concomitant outflow-improving procedures were performed.

Comparison between duplex scanning and angiographic findings in the evaluation of functional iliac obstruction in top endurance athletes.

OBJECTIVE: Review of a 10 year-experience, to evaluate the efficacy of pre-operative investigations in the detection of external iliac artery (EIA) endofibrosis in top endurance athletes. DESIGN: Retrospective study. MATERIALS: From September 1995 to March 2004, 13 highly-trained athletes (all men, mean age 32.3 years) underwent surgery for disease involving 14 lower limbs (11 left, one right, one bilateral). METHODS: We compared ultrasound scan (US) and digital subtraction angiography (DSA) data, at rest and at hip flexion with intra-operative findings for all 14 lower limbs. We analyzed the presence of stenosis in the external and common iliac arteries, the presence of psoas muscle arteries and the presence of excessive EIA length. RESULTS: In the affected limbs, before treatment, the mean ankle brachial index (ABI) at rest was 0.98 compared with 0.56 after exercise, p=0.0001. The sensitivities of the US vs DSA examination in the detection of external and common iliac artery stenosis were, respectively, 84.6 and 53.8% vs 53.8 and 12.5%. The muscle psoas artery was detected by DSA with a sensitivity of 57.1 and 100% specificity. For the detection of excessive EIA length, the sensitivity of US was 85.7% with 57.1% specificity. CONCLUSIONS: A fall of ABI after exercise proves the presence of a significant stenosis in symptomatic athletes. Color coded duplex ultrasonography is recommended for non-invasive imaging of suspected endofibrotic stenosis in young athletes, since it detects reliably both stenosis and elongation of iliacal arteries.

Comparison between direct clinical and digital photogrammetric measurements in patients with 22q11 microdeletion.

Thanks to recent advances in imaging and computing technology, photoanthropometry has become an increasingly helpful adjunct to obtain objective clinical evidence of morphologic abnormalities in patients with dysmorphic syndromes. The aim of this study was to evaluate measurements made using a new two-dimensional digital photogrammetry technique by comparison with direct clinical measurements. A total of 14 patients with 22q11 microdeletion were included in this study. There were seven females and seven males between 5 and 38 years of age. Sixteen direct clinical measurements were performed using a graduated anthropometric sliding caliper and angle meter. Photogrammetric measurements were made on digital photographs using a commercially available software package. After calibration to one in situ reference on frontal and profile views, photogrammetric measurements were compared to a total of 14 direct clinical measurements made in the same patients. Findings showed that photogrammetric measurements calibrated to an in situ reference were reliable especially on profile views. No statistical difference was found between 10 of the 14 measurements (P> 0.05) including eight of the nine measurements on profile views and two of the five measurements on frontal views. This study indicates that digital photogrammetry is a useful tool but there is still no reliable standard photographic measurement technique.

[MRI and in utero ventriculomegaly]. / IRM et ventriculomégalie in utero.

Ventriculomegaly constitutes the major indication of fetal brain MRI. MRI is therefore of utmost importance to look for a cause through the depiction of criteria of malformations and through the definition of criteria of destructive lesions. Malformations and destructive lesions are the most common causes of ventricular dilatation. Some challenging points are worth mentioning in term of mechanism with the challenge of hydrocephalus (in term of increased in intracranial pressure) and of isolated ventriculomegaly. The image itself is also challenging since a similar image may be of different origin. In term of natural history of fetal brain injury an irregular, nodular aspect of the ventricular wall and/or the germinal matrix is often the only pathologic MRI finding that is known to be of clastic origin. In term of prognosis the challenge is represented by the isolated mild ventriculomegaly, the literature being quite confusing. The purpose of this review paper is to highlight the underlying mechanisms and pathophysiology of ventricular dilatation based on results from the literature as well as from personal experience.

Amiodarone reduces procedures and costs related to atrial fibrillation in a controlled clinical trial.

BACKGROUND: Atrial fibrillation is the most common sustained cardiac arrhythmia, and engenders significant health care costs. The impact of various treatment options for atrial fibrillation on hospital costs has not been evaluated in a randomized trial. METHODS: We analysed 1-year follow-up data on 392 patients randomized to low dose amiodarone (200 mg. day(-1)) or alternative first-line therapy (sotalol or propafenone) in a multicentre trial (Canadian Trial of Atrial Fibrillation, CTAF). RESULTS: Patients in the amiodarone group had fewer electrical cardioversions (65 vs 109 for patients in the sotalol/propafenone group, P<0.0001), and pacemaker insertions (4 vs 11, P=0.07). The average amiodarone patient spent fewer days in hospital (0.47 vs 0.97, P=0.01), and incurred lower costs ($532 vs $898, P=0.03), for admissions where atrial fibrillation was the admitting diagnosis. Average total hospital costs per patient for all admissions, as well as average combined hospital and physician costs per patient, showed wide variations within the treatment arms and were not significantly different between groups. CONCLUSION: For patients in whom antiarrhythmic drug therapy is indicated, low dose amiodarone significantly reduces atrial fibrillation-related costs by reducing the number of atrial fibrillation-related procedures.

Atrioventricular interval optimization and exercise tolerance.

Modern pacemakers offer many programming options regarding the AV interval including the ability to vary AV intervals depending on whether atrial activity is paced or spontaneous and to shorten AV intervals with increasing rates. To determine if optimization of these features improves exercise tolerance, 14 patients with intact sinus node function and AV block treated with dual chamber pacemakers were enrolled in a randomized double-blind crossover trial. Doppler echocardiographic measurements of cardiac index and mitral flow were assessed over a range of programmable AV intervals at rest to determine each patient's optimal AV interval. Eleven patients completed serial graded exercise tests with spiroergometry after randomly programming the AV interval three ways in a crossover manner: fixed AV interval = 150 ms without rate adaptation (150/Fixed), fixed AVinterval = 150 ms with rate adaptation (150/R), or optimized AV interval with rate adaptive AV interval shortening (optimized/R). Exercise capacity was determined by maximum oxygen uptake. Ten men and four women, age 64 +/- 8 years, were enrolled. At rest, optimization of the AVintervalimproved the cardiac index by 21% (P < 0.001) and mitral flow by 13.4% (P < 0.001) when compared to least-favorable AV intervals. During exercise, no differences in maximum heart rates were noted. Maximum oxygen uptake was increased in both groups with rate adaptive AVinterval shortening when compared tofixed AVinterval without rate adaptation: 13.9% (adjusted P < 0.04) and 14.6% (adjusted P < 0.02) in optimized/R and 150/R, respectively. No differences were noted between optimized/R and 150/R. In conclusion, rate adaptive AV interval shortening improved exercise tolerance independent of changes in heart rate. However, optimization of the AV interval with Doppler echocardiography at rest did not further improve exercise capacity.

Prevention of nosocomial urinary tract infection in ICU patients: comparison of effectiveness of two urinary drainage systems.

STUDY OBJECTIVES: To determine whether the rate of acquisition of bacteriuria differs between the use of a complex closed drainage system (CCDS) with a preattached catheter, antireflux valve, drip chamber, and povidone-iodine releasing cartridge, and a two-chamber open drainage system (TCOS) in ICU patients. DESIGN: Prospective, nonrandomized, controlled trial. SETTING: Medical/surgical/trauma ICU in a university hospital. PATIENTS: Two hundred twenty-four ICU patients requiring an indwelling urinary catheter. INTERVENTION: We compared the rate of acquisition of bacteriuria in two groups of consecutive patients (n = 113 and n = 111, respectively) who underwent bladder catheterization with a TCOS during the first 6 months and with a CCDS during the next 6 months. Urinary catheters were managed by a team of trained nurses following the same written protocol. No prophylactic antibiotics were administered, either during management of catheter placements or catheter withdrawal, but 75% of patients received one or more antimicrobial medications for treatment of infected sites other than the urinary tract. Urine samples were obtained weekly for the duration of catheterization and within 24 h after catheter removal, and each time symptoms of urinary infection were suspected. Only patients who required an indwelling catheter for > 48 h were evaluated. MEASUREMENTS AND RESULTS: There was no statistical difference in the rate of bacteriuria between the two groups. Bacteriuria occurred in 11.5% and 13.5% of patients, and was diagnosed on day 14 +/- 8 and 13 +/- 9 of catheterization (mean +/- SD) for the TCOS and the CCDS, respectively. A CCDS cost $3 (US dollars) more than the TCOS. CONCLUSIONS: To our knowledge, this is the first study to compare the effectiveness of a TCOS and a CCDS in ICU patients. No differences were noted between the two systems (alpha = 0.05). The higher cost of a CCDS is not justified for ICU patients.

Craniofacial anthropometric analysis in patients with 22q11 microdeletion.

Microdeletions in the 22q11 region are associated with a wide range of overlapping phenotypes. The main manifestations of the syndrome include palatal anomalies such as cleft palate or velopharyngeal insufficiency, conotruncal heart defects, hypocalcemia, immune disorders, and minor facial anomalies. Because of the wide variability, facial changes appear to be the most constant manifestation of the syndrome and characteristic for informed physicians. The purpose of this study is to report the preliminary results of a detailed analysis of anthropometric data (35 measurements) in 15 patients (7 females and 8 males between 5 and 38 years of age, all white Europeans) with a 22q11 microdeletion. Objective anthropometric study showed that 19 measurements and 7 indexes were significantly different between 22q11 patients and normative database. The typical face showed a short forehead with an anterior vertical excess. Downslanting eyes and large binocular width were the most common anomalies in the orbital area. The nose showed anomalies with a large root, a short tip, and a narrow alar base. There was a narrowing of the mouth and thin lips. Ears were small and slightly disharmonic for the children. Statistical comparison between children (10 cases) and adults (5 cases) showed that craniofacial assessment was more demonstrative in children than in adults.

Catheter cryoablation of the atrioventricular node in patients with atrial fibrillation: a novel technology for ablation of cardiac arrhythmias.

INTRODUCTION: Recent animal studies demonstrated the feasibility and safety of applying percutaneous catheter cryoablation technology for ablation of arrhythmogenic sites. The studies also showed that reversible "ice mapping" can be performed before creating permanent lesions. We investigated the feasibility and safety of applying this new technology in man. METHODS AND RESULTS: Cryoablation of the AV node (AVN) using a 9-French quadripolar catheter with a 4-mm electrode tip was attempted in 12 patients (mean age 67.8 +/- 11.4 years) with refractory atrial fibrillation. Whereas technical issues prevented adequate tissue contact in two patients, complete AVN block was obtained in the remaining 10 patients after 4.8 +/- 1.9 cryoapplications lasting 5.5 +/- 0.2 minutes resulting in temperatures of -58.1 degrees +/- 5.4 degrees C. In all patients with sinus rhythm at the time of the procedure, cryomapping at warmer temperatures induced reversible AVN block and allowed confirmation of a successful site before definitive ablation. Intracardiac echocardiography was performed in three patients and allowed visualization of the cryocatheter-endocardial contact and cryolesion formation. No major procedural complications were reported. After 6 months of follow-up, 8 of 10 initially successful patients remained in complete block; 1 had partial recovery of AVN conduction manifested by atrial fibrillation with a slow ventricular response, and 1 fully recovered AVN conduction. CONCLUSION: (1) Catheter cryoablation of the AVN can be performed safely in man. (2) Reversible cryomapping is feasible and may offer an advantage over radiofrequency ablation. (3) Cryocatheter-endocardial contact and cryolesion growth can be monitored with intracardiac echocardiography.

Circadian variation of paroxysmal atrial fibrillation. PA3 Investigators. Atrial Pacing Peri-ablation for Prevention of Atrial Fibrillation Trial.

The circadian variation of paroxysmal atrial fibrillation (AF) was studied in 67 patients who received a dual-chamber pacemaker 3 months before a planned atrioventricular node ablation. A distinct circadian variation of AF was observed with 2 time peaks in initiation (1 in the early morning and 1 in the early evening hours), which was modulated by atrial pacing, the duration of AF, and the use of beta-adrenergic blocking agents.

Normal detrusor is more sensitive than hypertrophied detrusor to in vitro ischemia followed by re-oxygenation.

Partial outlet obstruction results in marked metabolic as well as contractile alterations. Specifically, the ratio of anaerobic to oxidative metabolism is significantly greater in hypertrophied than normal bladder smooth muscle, lactate dehydrogenase (LDH) and lactic acid production are increased, and the contractile apparatus is altered to allow for metabolically more efficient tension generation. In addition, contractile responses of hypertrophied bladder are apparently more resistant than those of normal bladder to hypoxia. In the current experiment, we studied the effects of in vitro ischemia (hypoxia + substrate deprivation) followed by an in vitro model of reperfusion (re-oxygenation + substrate replacement) on contractile responses of normal and hypertrophied urinary bladder strips. We used repetitive field stimulation (FS) during the hypoxic period as a model for hyperreflexia. The purpose of the current study was to compare the responses of normal and hypertrophied bladder smooth muscle to repetitive stimulation in the presence of in vitro ischemia followed by re-oxygenation and substrate replacement. Thirty-two rats were separated into four groups of eight each. The rats in groups 1 and 3 were subjected to partial outlet obstruction. Two weeks later, all rats were anesthetized; their bladders were isolated and cut into four strips. Each strip was mounted in an isolated bath, and after 1-hour incubation in Tyrode's solution containing glucose (in the presence of O(2)), contractile responses to FS, carbachol, and KCl were determined. After this first set of stimulations, the strips were incubated without glucose and in the presence of N(2) for 30 minutes and 1 hour (groups 1 and 2); and for 2 and 4 hours (groups 3 and 4). For groups 1 and 2, the tissues were stimulated at 5-minute intervals with FS at 32 Hz, 1-millisecond duration, 3-second trains (in vitro model of hyperreflexia). For groups 3 and 4, no stimulations were performed during the ischemic period. At the end of the ischemic period, all strips were washed and incubated for 1 hour in the presence of O(2) and with glucose. At the end of this incubation, all strips received a second set of stimulations. a) Partial outlet obstruction resulted in a significant increase in bladder weight. b) Responses to in vitro ischemia: After in vitro ischemia, contractile responses of both normal and hypertrophied tissues to FS were reduced to a significantly greater degree than were responses to carbachol and KCl. The rate of development of contractile dysfunction was significantly greater in normal bladder tissue strips than in hypertrophied bladder strips. c) Responses to repetitive stimulation: The rate of development of contractile dysfunction was significantly greater in all strips subjected to repetitive stimulation than in those not repetitively stimulated; in addition, normal bladder strips were more sensitive than hypertrophied strips to hypoxia and substrate deprivation-induced contractile dysfunction. The rate of contractile failure induced by in vitro ischemia followed by re-oxygenation and substrate replacement was significantly greater for normal bladder strips than for hypertrophied bladder strips. These results indicate that, after partial outlet obstruction, the hypertrophied tissue is more resistant than normal tissue to hypoxia and substrate deprivation.

Phenotype-genotype correlation in 91 patients with familial Mediterranean fever reveals a high frequency of cutaneomucous features.

OBJECTIVES: To describe the clinical manifestations of familial Mediterranean fever (FMF) in 91 patients from 47 families and provide data from the genetic study. P:atients and methods. We conducted a retrospective chart review of 91 patients (including 83 children aged <15 yr) from 47 families through a questionnaire and a specific database. The genetic analysis included complete screening of known mutations of the MEFV gene on chromosome 16p13.3. A positive diagnosis required at least two mutations, one on each chromosome. RESULTS: Our panel included 52 females and 39 males, with a mean age of 7.27 yr. Of the 47 families, 31 were non-Ashkenazi Jews, 10 were Armenians and six were from other ethnic groups. Clinical features included fever (100%), peritonitis (86%), pleuritis (56%), arthritis (34%) and myalgias (27%). We observed a high rate of cutaneous manifestations (47%); erythema, oedema and recurrent oral ulcers were the most frequent. Phenotype-genotype correlations showed a significant association of M694V homozygosity with earlier age of onset (P: = 0.044), fever >39 degrees C (P: = 0. 002), pleural crisis (P: = 0.0044), splenomegaly (P: = 0.0005) and arthritis (P: = 0.001). Associations with mucocutaneous features were as follows: erysipelas-like erythema (P: = 0.012), oedema (P: = 0.61, not significant) and oral ulcers (P: = 0.45, not significant). CONCLUSION: New phenotype-genotype correlations emerged from our study: homozygosity for the M694V mutation was associated with intensity of fever, splenomegaly and with erysipelas-like erythema. Apart from erysipelas-like erythema, no significant association was found between other cutaneous features and the genotype.

13C basal abundance of expired CO2 -definition of pre-requisites for kinetic breath tests.

A sufficiently stable rate of 13CO2 exhalation is necessary when the diagnostic 13CO2 breath tests are performed in healthy subjects and patients. The aim of the research was to define prerequisite conditions for kinetic breath tests in order to ensure a stable 13CO2 background. A 3-part protocol was developed. Part I: a study of the one-day variation of 13CO2 abundance in expired CO2 confirmed that shifts of the basal 13C abundance in breath are inherent in nature. Part II: a study of the variations of 13C enrichment after the ingestion of different meals and beverages showed that ingestion of food items containing C4 plant sugars, such as maize, induces a significant increase in isotopic abundance. Part III: a new test breakfast containing rice grain cereal, milk and orange juice was tested. This test meal induces no significant change on the basal 13CO2 abundance in healthy subjects. This new finding allows to avoid the fasting period normally required prior to a breath test which is sometimes difficult for children and pregnant women.

Randomized crossover comparison of DDDR versus VDD pacing after atrioventricular junction ablation for prevention of atrial fibrillation. The atrial pacing peri-ablation for paroxysmal atrial fibrillation (PA (3)) study investigators.

BACKGROUND: Some clinical data suggest that atrial-based pacing prevents paroxysmal atrial fibrillation (AF). This study tested the hypothesis that DDDR pacing compared with VDD pacing prevents AF after atrioventricular (AV) junction ablation. METHODS AND RESULTS: Patients were randomized to DDDR pacing (n=33) or to VDD pacing (n=34) after AV junction ablation and followed every 2 months for 6 months. Patients then crossed over to the alternate pacing mode and were followed for an additional 6 months. Primary analysis included the time to first recurrence of sustained AF (duration >5 minutes), total AF burden, and the development of permanent AF. The time to first episode of AF was similar in the DDDR group (0.37 days, 95% CI 0.1 to 1.3 days) and the VDD pacing group (0.5 days, 95% CI 0.2 to 1.7 days, P=NS). AF burden increased over time in both groups (P<0.01). At the 6-month follow-up, AF burden was 6.93 h/d (95% CI 4. 37 to 10.96 h/d) in the DDDR group and 6.30 h/d (95% CI 3.99 to 9.94 h/d) in the VDD group (P=NS). Twelve (35%) patients in the DDDR group and 11 (32%) patients in the VDD group had permanent AF within 6 months of ablation. Within 1 year of follow-up, 43% of patients had permanent AF. CONCLUSIONS: DDDR pacing compared with VDD pacing does not prevent paroxysmal AF over the long term in patients in the absence of antiarrhythmic drug therapy after total AV junction ablation. Many patients have permanent AF within the first year after ablation.

Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators.

BACKGROUND: The restoration and maintenance of sinus rhythm is a desirable goal in patients with atrial fibrillation, because the prevention of recurrences can improve cardiac function and relieve symptoms. Uncontrolled studies have suggested that amiodarone in low doses may be more effective and safer than other agents in preventing recurrence, but this agent has not been tested in a large, randomized trial. METHODS: We undertook a prospective, multicenter trial to test the hypothesis that low doses of amiodarone would be more efficacious in preventing recurrent atrial fibrillation than therapy with sotalol or propafenone. We randomly assigned patients who had had at least one episode of atrial fibrillation within the previous six months to amiodarone or to sotalol or propafenone, given in an open-label fashion. The patients in the group assigned to sotalol or propafenone underwent a second randomization to determine whether they would receive sotalol or propafenone first; if the first drug was unsuccessful the second agent was prescribed. Loading doses of the drugs were administered and electrical cardioversion was performed (if necessary) within 21 days after randomization for all patients in both groups. The follow-up period began 21 days after randomization. The primary end point was the length of time to a first recurrence of atrial fibrillation. RESULTS: Of the 403 patients in the study, 201 were assigned to amiodarone and 202 to either sotalol (101 patients) or propafenone (101 patients). After a mean of 16 months of follow-up, 71 of the patients who were assigned to amiodarone (35 percent) and 127 of those who were assigned to sotalol or propafenone (63 percent) had a recurrence of atrial fibrillation (P<0.001). Adverse events requiring the discontinuation of drug therapy occurred in 18 percent of the patients receiving amiodarone, as compared with 11 percent of those treated with sotalol or propafenone (P=0.06). CONCLUSIONS: Amiodarone is more effective than sotalol or propafenone for the prevention of recurrences of atrial fibrillation.